Basic Information
| Provider Information | |||||||||
| NPI: | 1568714590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | MICAH | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10211 DUPONT CIRCLE DR W STE A | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604898989 | ||||||||
| FaxNumber: | 7347638100 | ||||||||
| Practice Location | |||||||||
| Address1: | 10211 DUPONT CIRCLE DR W STE A | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604898989 | ||||||||
| FaxNumber: | 7347638100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2012 | ||||||||
| LastUpdateDate: | 10/07/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2901020824 | MI | N | Dental Providers | Dentist | General Practice | 1223X0400X | 12011754A | IN | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.