Healthcare Provider Details

I. General information

NPI: 1053397315
Provider Name (Legal Business Name): DIANE JOHNSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W MICHIGAN ST
INDIANAPOLIS IN
46202-5211
US

IV. Provider business mailing address

203 N INDIANA ST
MOORESVILLE IN
46158-1508
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-7433
  • Fax:
Mailing address:
  • Phone: 317-834-4933
  • Fax: 317-834-4935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12008858
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: