=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205120441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DONALD J JOHNSON DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2011
-----------------------------------------------------
Last Update Date | 06/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 W NEIDER AVE
-----------------------------------------------------
City | COEUR D'ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83815-9300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-667-4551
-----------------------------------------------------
Fax | 866-683-6479
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 W NEIDER AVE
-----------------------------------------------------
City | COEUR D'ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83815-9300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-667-4551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DONALD J JOHNSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 208-667-4551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D1677
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------