Healthcare Provider Details

I. General information

NPI: 1740660059
Provider Name (Legal Business Name): KRISTA JOHNSON D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 45TH ST S STE 108
FARGO ND
58103-3246
US

IV. Provider business mailing address

1018 31ST AVE W
WEST FARGO ND
58078-8245
US

V. Phone/Fax

Practice location:
  • Phone: 701-526-4652
  • Fax:
Mailing address:
  • Phone: 701-202-7805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD009240
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: