Provider Demographics
NPI:1194788141
Name:JOHNSON, DAVID CLARK (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CLARK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 E ELIZABETH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4066
Mailing Address - Country:US
Mailing Address - Phone:970-447-3746
Mailing Address - Fax:970-447-3747
Practice Address - Street 1:1120 E ELIZABETH ST
Practice Address - Street 2:SUITE G-5
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4044
Practice Address - Country:US
Practice Address - Phone:970-221-5050
Practice Address - Fax:970-221-5054
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO87861223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16728742Medicaid
CO551038Medicare UPIN