Provider Demographics
NPI:1821161910
Name:JOHNSON, KEVIN J (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
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:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56619-0338
Mailing Address - Country:US
Mailing Address - Phone:218-751-4523
Mailing Address - Fax:218-751-0285
Practice Address - Street 1:603 BEMIDJI AVE N
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3015
Practice Address - Country:US
Practice Address - Phone:218-751-4523
Practice Address - Fax:218-751-0285
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN628820100Medicaid