MEDICARE: MICHAEL D. JOHNSON, D.D.S.,P.C.

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	261QD0000X	Dental Clinic/Center	019.020007	IL

General Provider Information

NPI Number	:	1477801298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL D. JOHNSON, D.D.S.,P.C.

Provider Business Mailing Address
First Line	:	2090 LARKIN AVE
Second Line	:	UNIT ONE-REAR
City	:	ELGIN
State	:	IL
Zip	:	60123-5845
Country	:	US
Telephone Number	:	847-741-6217
Fax Number	:	847-741-6217

Provider Business Practice Location Address
First Line	:	2090 LARKIN AVE
Second Line	:	UNIT ONE-REAR
City	:	ELGIN
State	:	IL
Zip	:	60123-5845
Country	:	US
Telephone Number	:	847-741-6217
Fax Number	:	847-741-6217

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL DAVID JOHNSON
Credential	:	D.D.S.
Telephone Number	:	847-741-6217

Provider Enumeration Date	:	08/28/2012
Last Update Date	:	08/28/2012

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