Kirby Charles Johnson, DDS

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

10472DDS Issued in MN

Practice address

3905 Silver Lake Rd
St Anthony, MN 55421

Phone

(612) 788-9246

Fax

(612) 788-5511

NPI assigned

Jun 26, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Jul 20, 2022 through Jul 20, 2028

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Oral & Maxillofacial Surgery Specialists, PA

  • Oral and Maxillofacial Surgery (Dentist)
  • Waconia, MN
  • NPI 1770694812
  NPD (past) Authorized official
• Oral & Maxillofacial Surgery Specialists, PA

  • Oral and Maxillofacial Surgery (Dentist)
  • Maple Grove, MN
  • NPI 1902917057
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151280000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1023045341",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "320 CALAMUS CIRCLE",
            "city": "MEDINA",
            "state": "MN",
            "postal_code": "55340",
            "telephone_number": "612-788-9246",
            "fax_number": "612-788-5511"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3905 SILVER LAKE RD",
            "city": "ST ANTHONY",
            "state": "MN",
            "postal_code": "55421",
            "telephone_number": "612-788-9246",
            "fax_number": "612-788-5511"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JOHNSON",
        "first_name": "KIRBY",
        "middle_name": "CHARLES",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-26",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "MN",
            "license": "10472DDS",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Ayanle Jama
• Hodan Ahmed Jama
• Khalid Jama
• Maida Abdirizak Jama
• Osman Sheikh Ali Jama
• K Home Cares LLC
• Kaycie Rose Nutrition LLC
• Ayan Abdi Khalif
• Muna Abdi Khalif
• David Jun Kim, PHARMD

• Oral and Maxillofacial Surgery (Dentist) in St Anthony, MN
• Providers in St Anthony, MN by specialty
• Oral and Maxillofacial Surgery (Dentist) in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.