Healthcare Provider Details

I. General information

NPI: 1184738346
Provider Name (Legal Business Name): NICHOLAS CRAIG JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N CENTER ST
EAST ALTON IL
62024-1708
US

IV. Provider business mailing address

5753 ITASKA ST
SAINT LOUIS MO
63109-2835
US

V. Phone/Fax

Practice location:
  • Phone: 618-259-5563
  • Fax:
Mailing address:
  • Phone: 314-766-2724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: