Provider Demographics
NPI:1134211295
Name:JOHNSON, SCOTT ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALAN
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:P.O. BOX 1740
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83877
Mailing Address - Country:US
Mailing Address - Phone:208-773-5121
Mailing Address - Fax:208-777-9484
Practice Address - Street 1:1296 E POLSTON AVE STE A
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5217
Practice Address - Country:US
Practice Address - Phone:208-773-5121
Practice Address - Fax:208-777-9484
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD31221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice