Provider Demographics
NPI:1164546305
Name:JOHNSON, MARY CAROL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:CAROL
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 1:711 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50392-0001
Mailing Address - Country:US
Mailing Address - Phone:515-362-2676
Mailing Address - Fax:515-613-6452
Practice Address - Street 1:711 HIGH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50392-0001
Practice Address - Country:US
Practice Address - Phone:515-362-2676
Practice Address - Fax:515-613-6452
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6856122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0209320Medicaid
IA20932OtherDELTA DENTAL PROVIDER #