Healthcare Provider Details

I. General information

NPI: 1609484112
Provider Name (Legal Business Name): DAKODA APODACA-JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 JEFFCO BLVD STE 110
ARNOLD MO
63010-3999
US

IV. Provider business mailing address

3540 JEFFCO BLVD STE 110
ARNOLD MO
63010-3999
US

V. Phone/Fax

Practice location:
  • Phone: 636-461-0933
  • Fax:
Mailing address:
  • Phone: 636-461-0933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2020020659
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: