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General NPI Number Information
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NPI Number | 1124502984
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Entity Type | Individual
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Provider Name | KISSENDRAH SUE JOHNSON
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Gender | Female
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Dates
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Enumeration Date | 09/18/2018
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Last Update Date | 09/18/2018
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Provider Practice Location Address
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Address Line | 01 SAGEBRUSH STREET
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City | ISLETA
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State | NM
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Zip | 87022
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Country | US
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Telephone | 505-869-4866
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Fax | 502-869-4881
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Provider Business Mailing Address
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Address Line | PO BOX 640
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City | ISLETA
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State | NM
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Zip | 87022-0640
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Country | US
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Telephone | 505-869-3200
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Fax | 505-869-4881
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD4977
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License Number State | NM
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