Healthcare Provider Details

I. General information

NPI: 1225414683
Provider Name (Legal Business Name): LESLEY JOHNSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 N MICHIGAN ST
PITTSBURG KS
66762-2546
US

IV. Provider business mailing address

924 N BROADWAY ST
PITTSBURG KS
66762-3910
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-9873
  • Fax: 620-231-5062
Mailing address:
  • Phone: 620-231-6788
  • Fax: 620-231-2331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number11886
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: