Provider Demographics
NPI:1982652566
Name:JOHNSON, CHRISTOPHER G (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 W FOND DU LAC ST
Mailing Address - Street 2:PO BOX 419
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-9289
Mailing Address - Country:US
Mailing Address - Phone:920-748-7200
Mailing Address - Fax:
Practice Address - Street 1:1209 W FOND DU LAC ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-9289
Practice Address - Country:US
Practice Address - Phone:920-748-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001654122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33397200Medicaid