Provider Demographics
NPI:1265426316
Name:JOHNSON, MICHAEL P (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 GOOSE LN STE 204
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2186
Mailing Address - Country:US
Mailing Address - Phone:203-453-7700
Mailing Address - Fax:203-458-5085
Practice Address - Street 1:246 GOOSE LN STE 204
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2186
Practice Address - Country:US
Practice Address - Phone:203-453-4381
Practice Address - Fax:203-458-5085
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT94371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
V06048Medicare UPIN