Healthcare Provider Details

I. General information

NPI: 1588764856
Provider Name (Legal Business Name): CRAIG BRIAN JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25579 CHURCH ST
NISSWA MN
56468
US

IV. Provider business mailing address

PO BOX 157
NISSWA MN
56468
US

V. Phone/Fax

Practice location:
  • Phone: 218-963-2970
  • Fax: 218-963-9502
Mailing address:
  • Phone: 218-963-2970
  • Fax: 218-963-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11320
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1003
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: