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General NPI Number Information
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NPI Number | 1770672958
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Entity Type | Organization
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Legal Business Name | FRIENDLY DENTAL
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 1316 MCMILLAN ST
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City | WORTHINGTON
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State | MN
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Zip | 56187-1646
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Country | US
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Telephone | 507-376-5525
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Fax | 507-376-3796
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Provider Business Mailing Address
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Address Line | 1316 MCMILLAN ST
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City | WORTHINGTON
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State | MN
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Zip | 56187-1646
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Country | US
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Telephone | 507-376-5525
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Fax | 507-376-3796
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JERRY LEE JOHNSON
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Credential | DDS
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Telephone | 507-376-5525
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 10185
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License Number State | MN
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