Healthcare Provider Details

I. General information

NPI: 1962563874
Provider Name (Legal Business Name): TERESA EVELYN JOHNSON DDS, MS, MPH, FASGD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 DREW AVE SE
MADELIA MN
56062-1841
US

IV. Provider business mailing address

115 DREW AVE SE
MADELIA MN
56062-1841
US

V. Phone/Fax

Practice location:
  • Phone: 507-642-8742
  • Fax: 507-642-2926
Mailing address:
  • Phone: 507-642-8742
  • Fax: 507-642-2926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10071
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: