Healthcare Provider Details

I. General information

NPI: 1881677094
Provider Name (Legal Business Name): GREGORY JUSTIN JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 3RD AVE W
RICHARDTON ND
58652-0333
US

IV. Provider business mailing address

200 3RD AVE W
RICHARDTON ND
58652-0333
US

V. Phone/Fax

Practice location:
  • Phone: 701-974-2118
  • Fax: 701-974-2175
Mailing address:
  • Phone: 701-974-2118
  • Fax: 701-974-2175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1720
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: