Provider Demographics
NPI:1922160332
Name:JOHNSON, DANIEL THEODORE JR (DDS)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:THEODORE
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:TED
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:5995 OREN AVE NORTH
Mailing Address - Street 2:SUITE 101
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-5302
Mailing Address - Country:US
Mailing Address - Phone:651-439-7071
Mailing Address - Fax:651-439-0500
Practice Address - Street 1:5995 OREN AVE NORTH
Practice Address - Street 2:SUITE 101
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5302
Practice Address - Country:US
Practice Address - Phone:651-439-7071
Practice Address - Fax:651-439-0500
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10105122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist