Provider Demographics
NPI:1922290345
Name:JOHNSON, ABBY PERSHKE (DDS)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:PERSHKE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 AIR BASE RD
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811
Mailing Address - Country:US
Mailing Address - Phone:218-728-2117
Mailing Address - Fax:218-728-2700
Practice Address - Street 1:4419 AIR BASE RD
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1847
Practice Address - Country:US
Practice Address - Phone:218-728-2117
Practice Address - Fax:218-728-2700
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND124261223G0001X, 1223P0221X
TN100331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10033OtherLICENSE
MND12426OtherLICENSE