MEDICARE: MICHELE DAWN JOHNSON RDHAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	654	CA

General Provider Information

NPI Number	:	1205360088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELE DAWN JOHNSON RDHAP

Provider Business Mailing Address
First Line	:	PO BOX 903
Second Line	:	520 GREENWOOD AVE.
City	:	BLUE LAKE
State	:	CA
Zip	:	95525-0903
Country	:	US
Telephone Number	:	707-668-5683
Fax Number	:	707-845-0088

Provider Business Practice Location Address
First Line	:	520 GREENWOOD AVE.
Second Line	:
City	:	BLUE LAKE
State	:	CA
Zip	:	95525-0903
Country	:	US
Telephone Number	:	707-668-5683
Fax Number	:	707-845-0088

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2017
Last Update Date	:	04/18/2017

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