Provider Demographics
NPI:1295930279
Name:JOHNSON, AMANDA ANGEL (DDS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANGEL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ANGEL
Other - Last Name:ISAAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:389 15TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3017
Mailing Address - Country:US
Mailing Address - Phone:701-483-1385
Mailing Address - Fax:701-483-1388
Practice Address - Street 1:389 15TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3017
Practice Address - Country:US
Practice Address - Phone:701-483-1385
Practice Address - Fax:701-483-1388
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2007122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist