Healthcare Provider Details

I. General information

NPI: 1194963660
Provider Name (Legal Business Name): MATTHEW A JOHANSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11178 HURON ST STE 100
NORTHGLENN CO
80234-4370
US

IV. Provider business mailing address

3215 GENEVA ST
DENVER CO
80238-3345
US

V. Phone/Fax

Practice location:
  • Phone: 303-457-9617
  • Fax: 303-457-2405
Mailing address:
  • Phone: 303-868-3064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number10169
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: