Healthcare Provider Details

I. General information

NPI: 1942475744
Provider Name (Legal Business Name): DAVID M JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W CLAIREMONT AVE CHIPPEWA VALLEY TECHNICAL COLLEGE DENTAL HYGIENE CLINIC
EAU CLAIR WI
54701
US

IV. Provider business mailing address

620 W CLAIREMONT AVE CHIPPEWA VALLEY TECHNICAL COLLEGE DENTAL HYGIENE CLINIC
EAU CLAIR WI
54701
US

V. Phone/Fax

Practice location:
  • Phone: 715-833-6370
  • Fax: 715-833-6447
Mailing address:
  • Phone: 715-833-6370
  • Fax: 715-833-6447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5000315015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: