Provider Demographics
NPI:1871848598
Name:JOHNSON, PAUL (DMD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E STE 1000C
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3459
Mailing Address - Country:US
Mailing Address - Phone:208-734-7415
Mailing Address - Fax:
Practice Address - Street 1:1411 FALLS AVE E STE 1000C
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3459
Practice Address - Country:US
Practice Address - Phone:208-734-7415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4745122300000X
WADE60293839122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1023850Medicaid