Provider Demographics
NPI:1760498778
Name:JOHNSON, JEFFREY JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JAMES
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 1:2405 CHAMBERSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3203
Mailing Address - Country:US
Mailing Address - Phone:218-269-1189
Mailing Address - Fax:
Practice Address - Street 1:FOND DU LAC HUMAN SERVICES DIVISION
Practice Address - Street 2:927 TRETTLE LANE
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:218-878-2188
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND122661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNBJ9870305OtherDEA