Healthcare Provider Details

I. General information

NPI: 1437292570
Provider Name (Legal Business Name): MARY BETH JOHNSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 06/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 264, MP 388
POLACCA AZ
86042
US

IV. Provider business mailing address

HOPI HEALTH CARE CENTER KEAMS CANYON S.U. PO BOX 4000
POLACCA AZ
86042
US

V. Phone/Fax

Practice location:
  • Phone: 928-737-6162
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30020478
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number30-020478
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: