Provider Demographics
NPI:1952389629
Name:JOHNSON, RICHARD LEWIS SR (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEWIS
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1040
Mailing Address - Street 2:121 MAIN STREET
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-1040
Mailing Address - Country:US
Mailing Address - Phone:231-536-1000
Mailing Address - Fax:231-536-9705
Practice Address - Street 1:121 MAIN STREET
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727
Practice Address - Country:US
Practice Address - Phone:231-536-1000
Practice Address - Fax:231-536-9705
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010106121223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics