Provider Demographics
NPI:1770993073
Name:JOHNSON, ROSS LAWRENCE (DDS, MSD)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:LAWRENCE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-0901
Mailing Address - Country:US
Mailing Address - Phone:605-663-4865
Mailing Address - Fax:
Practice Address - Street 1:2525 W MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2439
Practice Address - Country:US
Practice Address - Phone:605-663-4865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202269122300000X
SDD1330122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist