Healthcare Provider Details

I. General information

NPI: 1164633061
Provider Name (Legal Business Name): ROGER C JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 3RD ST NE
DEVILS LAKE ND
58301-3015
US

IV. Provider business mailing address

503 3RD STREET
DEVILS LAKE ND
58301-3015
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-4961
  • Fax:
Mailing address:
  • Phone: 701-662-4961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberND1574
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: