Healthcare Provider Details

I. General information

NPI: 1801687173
Provider Name (Legal Business Name): NISSWA DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25579 CHURCH ST
NISSWA MN
56468-2834
US

IV. Provider business mailing address

PO BOX 157
NISSWA MN
56468-0157
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CRAIG BRIAN JOHNSON
Title or Position: OWNER / DENTIST
Credential: DDS
Phone: 218-963-2970