Provider Demographics
NPI:1114925955
Name:JOHNSON, JAMIE L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:L
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 1:1001 S PUEBLO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1682
Mailing Address - Country:US
Mailing Address - Phone:719-564-0990
Mailing Address - Fax:719-564-6817
Practice Address - Street 1:1001 S PUEBLO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1682
Practice Address - Country:US
Practice Address - Phone:719-564-0990
Practice Address - Fax:719-564-6817
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO73801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02073807Medicaid