Healthcare Provider Details

I. General information

NPI: 1164639167
Provider Name (Legal Business Name): DANIEL P. JOHNSON DDS, PC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 15TH AVE STE 101
LONGMONT CO
80501-2700
US

IV. Provider business mailing address

630 15TH AVE STE 101
LONGMONT CO
80501-2700
US

V. Phone/Fax

Practice location:
  • Phone: 303-485-0300
  • Fax: 303-485-0777
Mailing address:
  • Phone: 303-485-0300
  • Fax: 303-485-0777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7778
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: