Provider Demographics
NPI:1457799884
Name:JOHNSON, KATIE KREMER (DDS)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:KREMER
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 ALLAN AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-2405
Mailing Address - Country:US
Mailing Address - Phone:320-290-9339
Mailing Address - Fax:
Practice Address - Street 1:115 DREW AVE SE STE 202
Practice Address - Street 2:
Practice Address - City:MADELIA
Practice Address - State:MN
Practice Address - Zip Code:56062-1870
Practice Address - Country:US
Practice Address - Phone:507-642-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13247122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist