MEDICARE: DR. TODD A 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	9081	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	24227JO	OTHER	MN	BLUE CROSS & BLUE SHIELD

General Provider Information

NPI Number	:	1871550640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TODD A JOHNSON D.D.S.

Provider Business Mailing Address
First Line	:	5207 UNIVERSITY AVE NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-1649
Country	:	US
Telephone Number	:	763-572-8040
Fax Number	:	763-502-2310

Provider Business Practice Location Address
First Line	:	5207 UNIVERSITY AVE NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-1649
Country	:	US
Telephone Number	:	763-572-8040
Fax Number	:	763-502-2310

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

Provider Enumeration Date	:	04/27/2006
Last Update Date	:	07/08/2007

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