Provider Demographics
NPI:1750474706
Name:JOHNSON, DALE ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:DALE
Other - Middle Name:ALAN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1717 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4695
Mailing Address - Country:US
Mailing Address - Phone:815-233-9777
Mailing Address - Fax:815-232-1312
Practice Address - Street 1:1717 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4695
Practice Address - Country:US
Practice Address - Phone:815-233-9777
Practice Address - Fax:815-232-1312
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist