Healthcare Provider Details

I. General information

NPI: 1316292097
Provider Name (Legal Business Name): FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1756 VINE ST
DENVER CO
80206-1120
US

IV. Provider business mailing address

1756 VINE STREET
DENVER CO
80206
US

V. Phone/Fax

Practice location:
  • Phone: 303-322-1177
  • Fax: 303-322-1199
Mailing address:
  • Phone: 303-322-1177
  • Fax: 303-322-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number104176
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number105493
License Number StateCO

VIII. Authorized Official

Name: DR. COLLIS JOHNSON JR.
Title or Position: DENTIST OWNER
Credential: DDS
Phone: 303-322-1177