Healthcare Provider Details

I. General information

NPI: 1962763193
Provider Name (Legal Business Name): KELLY ANN JOHNSON D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 02/11/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 N WEBB RD STE 301
WICHITA KS
67206-3410
US

IV. Provider business mailing address

229 S BLECKLEY DR
WICHITA KS
67218-1521
US

V. Phone/Fax

Practice location:
  • Phone: 316-687-2110
  • Fax:
Mailing address:
  • Phone: 316-250-6090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberKS60821
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: