Provider Demographics
NPI:1962763193
Name:JOHNSON, KELLY ANN (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 S BLECKLEY DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1521
Mailing Address - Country:US
Mailing Address - Phone:316-250-6090
Mailing Address - Fax:
Practice Address - Street 1:2020 N WEBB RD STE 301
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3410
Practice Address - Country:US
Practice Address - Phone:316-687-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS60821204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery