Provider Demographics
NPI:1891841714
Name:JOHNSON, RONALD STEPHEN (DMD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:STEPHEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 AREDO DE CARLOS
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4063
Mailing Address - Country:US
Mailing Address - Phone:505-326-3555
Mailing Address - Fax:
Practice Address - Street 1:1510B E 20TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9033
Practice Address - Country:US
Practice Address - Phone:505-327-6151
Practice Address - Fax:505-327-7580
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD14661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice