MEDICARE: MR. DANIEL THEODORE JOHNSON JR. 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	122300000X	Dentist	D10105	MN

General Provider Information

NPI Number	:	1922160332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANIEL THEODORE JOHNSON JR. DDS

Provider Business Mailing Address
First Line	:	5995 OREN AVE NORTH
Second Line	:	SUITE 101
City	:	STILLWATER
State	:	MN
Zip	:	55082-5302
Country	:	US
Telephone Number	:	651-439-7071
Fax Number	:	651-439-0500

Provider Business Practice Location Address
First Line	:	5995 OREN AVE NORTH
Second Line	:	SUITE 101
City	:	STILLWATER
State	:	MN
Zip	:	55082-5302
Country	:	US
Telephone Number	:	651-439-7071
Fax Number	:	651-439-0500

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

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	07/08/2007

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