Provider Demographics
NPI:1003286055
Name:JOHNSON, MARY ANN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5147
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:
Practice Address - Street 1:320 COMANCHE ST.
Practice Address - Street 2:
Practice Address - City:KIOWA
Practice Address - State:CO
Practice Address - Zip Code:80117
Practice Address - Country:US
Practice Address - Phone:720-389-9763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002027171223G0001X, 122300000X
GADN011093122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80200079Medicaid