MEDICARE: DR. ORVIS JOHNSON D.D.S

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	5000785-015	WI

General Provider Information

NPI Number	:	1679596316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ORVIS JOHNSON D.D.S

Provider Business Mailing Address
First Line	:	825 PROSPECT AVE
Second Line	:
City	:	NORTH FOND DU LAC
State	:	WI
Zip	:	54937-1365
Country	:	US
Telephone Number	:	920-923-0310
Fax Number	:	920-923-5335

Provider Business Practice Location Address
First Line	:	825 PROSPECT AVE
Second Line	:
City	:	NORTH FOND DU LAC
State	:	WI
Zip	:	54937-1365
Country	:	US
Telephone Number	:	920-923-0310
Fax Number	:	920-923-5335

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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