=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457486391
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. R. W. JOHNSON, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 W LYON ST
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56258-1308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-532-2233
-----------------------------------------------------
Fax | 507-532-2234
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 W LYON ST P. O. BOX 448
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56258-1308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-532-2233
-----------------------------------------------------
Fax | 507-532-2234
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | DR. RANDY W JOHNSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 507-532-2233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D7816
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------