Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DEN-DEN-LIC-15423 | MT |
NPI | 1003300989 |
---|---|
Provider Name | Dr. Timothy Chapman Johnson |
First Address | Polson, MT 59860-2119 |
Second Address | Polson, MT 59860-2119 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2018 |
Last Update Date | 21/01/2021 |