Healthcare Provider Details

I. General information

NPI: 1679596316
Provider Name (Legal Business Name): ORVIS JOHNSON D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 PROSPECT AVE
NORTH FOND DU LAC WI
54937-1365
US

IV. Provider business mailing address

825 PROSPECT AVE
NORTH FOND DU LAC WI
54937-1365
US

V. Phone/Fax

Practice location:
  • Phone: 920-923-0310
  • Fax: 920-923-5335
Mailing address:
  • Phone: 920-923-0310
  • Fax: 920-923-5335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5000785-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: