Healthcare Provider Details

I. General information

NPI: 1336199850
Provider Name (Legal Business Name): KARL GUSTAVE JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CENTRAL AV
OSSEO MN
55369
US

IV. Provider business mailing address

PO BOX 23029
RICHFIELD MN
55423
US

V. Phone/Fax

Practice location:
  • Phone: 763-425-3023
  • Fax: 763-425-8450
Mailing address:
  • Phone: 612-861-9123
  • Fax: 612-861-9155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11709
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: