Healthcare Provider Details

I. General information

NPI: 1609828870
Provider Name (Legal Business Name): DALE JOHNSON OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 CEDAR ST
SAULT SAINTE MARIE MI
49783-2410
US

IV. Provider business mailing address

724 CEDAR ST
SAULT SAINTE MARIE MI
49783-2410
US

V. Phone/Fax

Practice location:
  • Phone: 906-632-2020
  • Fax:
Mailing address:
  • Phone: 906-632-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number4901002749
License Number StateMI

VIII. Authorized Official

Name: DALE JOHNSON
Title or Position: MANAGER
Credential: OD
Phone: 906-632-2020