Provider Demographics
NPI:1093384687
Name:JOHNSON, COLE
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 WOODCREEK DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-8096
Mailing Address - Country:US
Mailing Address - Phone:317-910-2089
Mailing Address - Fax:
Practice Address - Street 1:2017 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-2824
Practice Address - Country:US
Practice Address - Phone:317-910-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013639A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice