MEDICARE: JOEL MICAH JOHNSON DDS

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	1223G0001X	General Practice Dentistry	2901020824	MI
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	12011754A	IN

General Provider Information

NPI Number	:	1568714590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL MICAH JOHNSON DDS

Provider Business Mailing Address
First Line	:	10211 DUPONT CIRCLE DR W STE A
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1625
Country	:	US
Telephone Number	:	260-489-8989
Fax Number	:	734-763-8100

Provider Business Practice Location Address
First Line	:	10211 DUPONT CIRCLE DR W STE A
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1625
Country	:	US
Telephone Number	:	260-489-8989
Fax Number	:	734-763-8100

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

Provider Enumeration Date	:	10/15/2012
Last Update Date	:	10/07/2014

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