Basic Information
Provider Information | |||||||||
NPI: | 1003286055 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3205 N ACADEMY BLVD | ||||||||
Address2: | SUITE 130 | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809175147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7196325700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 320 COMANCHE ST. | ||||||||
Address2: |   | ||||||||
City: | KIOWA | ||||||||
State: | CO | ||||||||
PostalCode: | 80117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7203899763 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2015 | ||||||||
LastUpdateDate: | 04/04/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DEN.00202717 | CO | Y |   | Dental Providers | Dentist | General Practice | 122300000X | DN011093 | GA | N |   | Dental Providers | Dentist |   | 122300000X | DEN.00202717 | CO | N |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 80200079 | 05 | CO |   | MEDICAID |