Healthcare Provider Details

I. General information

NPI: 1093384687
Provider Name (Legal Business Name): COLE JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 S WESTERN AVE
MARION IN
46953-2824
US

IV. Provider business mailing address

2234 WOODCREEK DR
AVON IN
46123-8096
US

V. Phone/Fax

Practice location:
  • Phone: 317-910-2089
  • Fax:
Mailing address:
  • Phone: 317-910-2089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12013639A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: