Provider Demographics
NPI:1871681825
Name:JOHNSON, DALE
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 N MAIN AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-5948
Mailing Address - Country:US
Mailing Address - Phone:605-367-8793
Mailing Address - Fax:605-367-8247
Practice Address - Street 1:521 N MAIN AVE
Practice Address - Street 2:STE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-5948
Practice Address - Country:US
Practice Address - Phone:605-367-8793
Practice Address - Fax:605-367-8247
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM8221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5350010Medicaid