Provider Demographics
NPI:1881894137
Name:JOHNSON, KRIS DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:KRIS
Middle Name:DAVID
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 1:11800 ABERDEEN ST. NE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449
Mailing Address - Country:US
Mailing Address - Phone:763-772-0330
Mailing Address - Fax:763-772-0354
Practice Address - Street 1:11800 ABERDEEN ST. NE
Practice Address - Street 2:SUITE 140
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449
Practice Address - Country:US
Practice Address - Phone:763-772-0330
Practice Address - Fax:763-772-0354
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND105851223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics