Provider Demographics
NPI:1194963660
Name:JOHANSON, MATTHEW A (DMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:JOHANSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 GENEVA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-3345
Mailing Address - Country:US
Mailing Address - Phone:303-868-3064
Mailing Address - Fax:
Practice Address - Street 1:11178 HURON ST
Practice Address - Street 2:STE 100
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-4370
Practice Address - Country:US
Practice Address - Phone:303-457-9617
Practice Address - Fax:303-457-2405
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101691223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics