Provider Demographics
NPI:1528066404
Name:JOHNSON, CHARLES WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
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 1:1600 23RD AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6071
Mailing Address - Country:US
Mailing Address - Phone:970-353-4329
Mailing Address - Fax:970-353-0526
Practice Address - Street 1:1600 23RD AVE STE 200
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6071
Practice Address - Country:US
Practice Address - Phone:970-353-4329
Practice Address - Fax:970-353-0526
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO70491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO7049OtherDENTAL LICENSE NUMBER
COBJ4404771OtherDEA REGISTRATION NUMBER