Provider Demographics
NPI:1780851014
Name:JOHNSON FAMILY DENTISTRY, PC
Entity Type:Organization
Organization Name:JOHNSON FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-662-4961
Mailing Address - Street 1:503 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-3015
Mailing Address - Country:US
Mailing Address - Phone:701-662-4961
Mailing Address - Fax:701-662-4962
Practice Address - Street 1:503 3RD ST NE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-3015
Practice Address - Country:US
Practice Address - Phone:701-662-4961
Practice Address - Fax:701-662-4962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40104Medicaid