Provider Demographics
NPI:1144618307
Name:COLE J. JOHNSON DDS PA
Entity Type:Organization
Organization Name:COLE J. JOHNSON DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COLE
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-452-2995
Mailing Address - Street 1:2420 S 51ST CT
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3669
Mailing Address - Country:US
Mailing Address - Phone:479-452-2995
Mailing Address - Fax:
Practice Address - Street 1:2420 S 51ST CT
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3669
Practice Address - Country:US
Practice Address - Phone:479-452-2995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR38671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR199375608Medicaid