Healthcare Provider Details

I. General information

NPI: 1083533327
Provider Name (Legal Business Name): CODY STEPHEN JOHNSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

16 LEDGEN WOOD RD
NORTH STONINGTON CT
06359-1003
US

V. Phone/Fax

Practice location:
  • Phone: 312-516-4330
  • Fax:
Mailing address:
  • Phone: 860-501-4736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number018.012557
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: