Provider Demographics
NPI:1265961379
Name:JOHNSON, PAUL A (DMD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 N CROSBY AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-3333
Mailing Address - Country:US
Mailing Address - Phone:608-752-7931
Mailing Address - Fax:
Practice Address - Street 1:107 N CROSBY AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3333
Practice Address - Country:US
Practice Address - Phone:608-752-7931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10015921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice