Active NPI
Jeremy Johnson
- Orthodontics and Dentofacial Orthopedics Dentistry
- Willmar, MN
National Provider Identifier
1548484652
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Orthodontics and Dentofacial Orthopedics Dentistry
- License
- D11637
- Practice address
- 1100 19TH Ave SW
Suite 1
Willmar, MN 56201-5288 - Phone
- (320) 325-3102
- NPI assigned
- Apr 12, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Orthodontics and Dentofacial Orthopedics Dentistry | 1223X0400X | D11637 | MN | Primary |
Addresses
Primary practice location
1100 19TH Ave SW
Suite 1
Willmar, MN 56201-5288
Mailing address
1100 19TH Ave SW
Suite 1
Willmar, MN 56201-5288
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D11637 | MN | MD | Orthodontics and Dentofacial Orthopedic Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1176336000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1649894400000",
"number": "1548484652",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1100 19TH AVE SW",
"address_2": "SUITE 1",
"city": "WILLMAR",
"state": "MN",
"postal_code": "562015288"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1100 19TH AVE SW",
"address_2": "SUITE 1",
"city": "WILLMAR",
"state": "MN",
"postal_code": "562015288",
"telephone_number": "320-325-3102"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JOHNSON",
"first_name": "JEREMY",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-04-12",
"last_updated": "2022-04-14",
"certification_date": "2022-04-14",
"status": "A"
},
"taxonomies": [
{
"code": "1223X0400X",
"taxonomy_group": "",
"desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
"state": "MN",
"license": "D11637",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Willmar, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 14, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.