Provider Demographics
NPI:1285260927
Name:JOHNSON ORTHODONTICS
Entity type:Organization
Organization Name:JOHNSON ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-432-9807
Mailing Address - Street 1:5850 TUTT CENTER PT STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-3520
Mailing Address - Country:US
Mailing Address - Phone:719-596-3081
Mailing Address - Fax:
Practice Address - Street 1:5850 TUTT CENTER PT STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-3520
Practice Address - Country:US
Practice Address - Phone:719-596-3081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHNSON ORTHODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21232571Medicaid