Provider Demographics
NPI:1750651527
Name:JOHNSON FAMILY DENTAL CARE LLC
Entity Type:Organization
Organization Name:JOHNSON FAMILY DENTAL CARE LLC
Other - Org Name:JOHNSON FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-532-3104
Mailing Address - Street 1:401 JEWETT ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-2605
Mailing Address - Country:US
Mailing Address - Phone:507-532-3104
Mailing Address - Fax:507-537-1347
Practice Address - Street 1:401 JEWETT ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2605
Practice Address - Country:US
Practice Address - Phone:507-532-3104
Practice Address - Fax:507-537-1347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
810572OtherUNITED CONCORDIA
46120JOOtherBLUE CROSS BLUE SHIELD
128218200OtherMINNESOTA MEDICAL ASSISTANCE