MEDICARE: ROSS LAWRENCE JOHNSON DDS, MSD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	00202269	CO
2	122300000X	Dentist	D1330	SD

General Provider Information

NPI Number	:	1770993073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSS LAWRENCE JOHNSON DDS, MSD

Provider Business Mailing Address
First Line	:	2525 W MAIN ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-0901
Country	:	US
Telephone Number	:	605-663-4865
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 W MAIN ST STE 206
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2439
Country	:	US
Telephone Number	:	605-663-4865
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2014
Last Update Date	:	06/01/2022

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