Healthcare Provider Details

I. General information

NPI: 1780800581
Provider Name (Legal Business Name): ANDREW R JOHANN D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 PENROSE PL SUITE 102
BOULDER CO
80301-1809
US

IV. Provider business mailing address

3400 PENROSE PL SUITE 102
BOULDER CO
80301-1809
US

V. Phone/Fax

Practice location:
  • Phone: 303-449-9850
  • Fax: 303-447-1127
Mailing address:
  • Phone: 303-449-9850
  • Fax: 303-447-1127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number7998
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: