Provider Demographics
NPI:1871550640
Name:JOHNSON, TODD A (DDS)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5207 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-1649
Mailing Address - Country:US
Mailing Address - Phone:763-572-8040
Mailing Address - Fax:763-502-2310
Practice Address - Street 1:5207 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-1649
Practice Address - Country:US
Practice Address - Phone:763-572-8040
Practice Address - Fax:763-502-2310
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN90811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24227JOOtherBLUE CROSS & BLUE SHIELD