Provider Demographics
NPI:1457662983
Name:JOHNSON, ANDREW C (DDS)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:C
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 1:5110 W 26TH ST
Mailing Address - Street 2:UNIT 5
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-3520
Mailing Address - Country:US
Mailing Address - Phone:605-759-5583
Mailing Address - Fax:605-339-7682
Practice Address - Street 1:5110 W 26TH ST
Practice Address - Street 2:UNIT 5
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-3520
Practice Address - Country:US
Practice Address - Phone:605-759-5583
Practice Address - Fax:605-339-7682
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD0935122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist