Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | D14501 | MN |
N | 1223S0112X | Oral and Maxillofacial Surgeon | DE60642383 | WA |
NPI | 1073860854 |
---|---|
Provider Name | Dr. Michael C Johnson |
First Address | Excelsior, MN 55331-1903 |
Second Address | Excelsior, MN 55331-1903 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2012 |
Last Update Date | 11/03/2021 |