Provider Demographics
NPI:1942463898
Name:MIIN, JOHNSON C (DDS, MSE)
Entity Type:Individual
Prefix:
First Name:JOHNSON
Middle Name:C
Last Name:MIIN
Suffix:
Gender:M
Credentials:DDS, MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1351 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7153
Practice Address - Country:US
Practice Address - Phone:508-587-2000
Practice Address - Fax:508-597-3552
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS390200000X
KY8512122300000X
MADN18564661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist