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Organization
FRIENDLY DENTAL
Active
Organization
FRIENDLY DENTAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JERRY LEE JOHNSON DDS (PRESIDENT)
(507) 376-5525
Entity
Organization
Contact information
Practice address
1316 MCMILLAN ST, WORTHINGTON, MN 56187-1646
(507) 376-5525
(507) 376-3796
Mailing address
1316 MCMILLAN ST, WORTHINGTON, MN 56187-1646
(507) 376-5525
(507) 376-3796
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
10185
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0964114
DELTA
IA
01
—
10185
DELTA
FM
01
—
46483JO
BLUE CROSS BLUE SHIELD
—
01
—
675-2375
TAX ID
MN
01
—
687623400
MINNESOTA MEDICAID - OFC.
MN
01
—
820-6852
UNITED CONCORDIA
—
Enumeration date
10/12/2006
Last updated
03/07/2023
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