Healthcare Provider Details

I. General information

NPI: 1376453472
Provider Name (Legal Business Name): POUDRE VALLEY PERIODONTICS & DENTAL IMPLANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 ROBERTSON ST
FORT COLLINS CO
80524-3926
US

IV. Provider business mailing address

1029 ROBERTSON ST
FORT COLLINS CO
80524-3926
US

V. Phone/Fax

Practice location:
  • Phone: 970-447-3746
  • Fax: 970-447-3747
Mailing address:
  • Phone: 970-447-3746
  • Fax: 970-447-3747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DAVID CLARK JOHNSON
Title or Position: PRESIDENT/OWNER
Credential: DDS, MS
Phone: 970-447-3746