Provider Demographics
NPI:1114307568
Name:JOHNSON, KRESTINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRESTINA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 S RANGELINE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-8850
Mailing Address - Country:US
Mailing Address - Phone:317-846-3539
Mailing Address - Fax:
Practice Address - Street 1:912 S RANGELINE RD STE 201
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8850
Practice Address - Country:US
Practice Address - Phone:317-846-3539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012299A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist