Healthcare Provider Details

I. General information

NPI: 1932624178
Provider Name (Legal Business Name): JESSE JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1137 COMMERCIAL DR SE
RIO RANCHO NM
87124-4658
US

IV. Provider business mailing address

9201 EAGLE RANCH RD NW
ALBUQUERQUE NM
87114
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-9399
  • Fax:
Mailing address:
  • Phone: 505-553-3607
  • Fax: 505-890-2949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD4776
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: