Individual
DR. JERRY LEE JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S
Contact information
Practice address
1316 MCMILLAN ST, WORTHINGTON, MN 56187-1646
(507) 376-5525
(507) 376-3796
Mailing address
29847 260TH ST, WORTHINGTON, MN 56187-6365
(507) 376-9253
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
10185
MN
1223G0001X
General Practice Dentistry
7092
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0964114
DELTA
IA
01
—
10185
DELTA
MN
01
—
176K2JO
BCBS
IA
01
—
46482JO
BCBS
MN
05
—
687623400
—
MN
01
—
820-685
UNITED CONCORDIA
—
Enumeration date
06/28/2006
Last updated
07/08/2007
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