Provider Demographics
NPI:1265711659
Name:KEITH A. JOHNSON, DDS, PC
Entity type:Organization
Organization Name:KEITH A. JOHNSON, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:641-592-2200
Mailing Address - Street 1:206 E. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:IA
Mailing Address - Zip Code:50450
Mailing Address - Country:US
Mailing Address - Phone:641-592-2200
Mailing Address - Fax:641-592-2202
Practice Address - Street 1:206 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:IA
Practice Address - Zip Code:50450
Practice Address - Country:US
Practice Address - Phone:641-592-2200
Practice Address - Fax:641-592-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA#61951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty