Provider Demographics
NPI:1710327051
Name:JOHNSON, MICHAEL S (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 9TH AVE S STE F
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8712
Mailing Address - Country:US
Mailing Address - Phone:701-364-9990
Mailing Address - Fax:701-364-9990
Practice Address - Street 1:2701 9TH AVE S STE F
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8712
Practice Address - Country:US
Practice Address - Phone:701-364-9990
Practice Address - Fax:701-364-9990
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2176122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist