Provider Demographics
NPI:1184738346
Name:JOHNSON, NICHOLAS CRAIG (DDS)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:CRAIG
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 1:5753 ITASKA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2835
Mailing Address - Country:US
Mailing Address - Phone:314-766-2724
Mailing Address - Fax:
Practice Address - Street 1:50 N CENTER ST
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-1708
Practice Address - Country:US
Practice Address - Phone:618-259-5563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist