Kirby Melvin Johnson, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D13361 Issued in MN

Practice address

163 Highway 23 NE Ste 1
Spicer, MN 56288-9735

Phone

(320) 796-2158

Fax

(320) 409-1180

NPI assigned

Oct 23, 2014

Last updated

Jan 27, 2023By the provider in NPPES

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

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

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

• Kirby M. Johnson, D.D.S., LLC

  dba Green Lake Dental

  • General Practice Dentistry
  • Spicer, MN
  • NPI 1841686359
  NPD Authorized official

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

{
    "created_epoch": "1414022400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1674777600000",
    "number": "1629473442",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "163 HIGHWAY 23 NE STE 1",
            "city": "SPICER",
            "state": "MN",
            "postal_code": "562889735",
            "telephone_number": "320-796-2158",
            "fax_number": "320-409-1180"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "163 HIGHWAY 23 NE STE 1",
            "city": "SPICER",
            "state": "MN",
            "postal_code": "562889735",
            "telephone_number": "320-796-2158",
            "fax_number": "320-409-1180"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JOHNSON",
        "first_name": "KIRBY",
        "middle_name": "MELVIN",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-10-23",
        "last_updated": "2023-01-27",
        "certification_date": "2023-01-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "D13361",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Janaya Jean Marie Evenson, RN, CNP
• Focus Chiropractic & Wellness
• Fourth Avenue Homes Inc. (First Step Quality Services)
• Glacial Lakes Aesthetics LLC
• Green Lake Thrifty White Drug Inc
• Kirby M. Johnson, D.D.S., LLC (Green Lake Dental)
• Tammie Lyn Knick, LICSW
• Jacob Kretschmar, PT, DPT
• Elizabeth J Mangen, PA-C
• Benjamin Marvin Olson

• General Practice Dentistry in Spicer, MN
• Providers in Spicer, MN by specialty
• General Practice Dentistry in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 27, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.