Healthcare Provider Details

I. General information

NPI: 1104999069
Provider Name (Legal Business Name): ROBERT J JOHNSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LAKE ST STE 101
ONTONAGON MI
49953-1034
US

IV. Provider business mailing address

400 LAKE ST STE 101
ONTONAGON MI
49953-1034
US

V. Phone/Fax

Practice location:
  • Phone: 906-884-4040
  • Fax: 906-884-4080
Mailing address:
  • Phone: 906-884-4040
  • Fax: 906-884-4080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901009242
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: