Provider Demographics
NPI:1215025101
Name:JOHNSON, COREY IVAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:IVAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 GRAND AVE
Mailing Address - Street 2:STE 109
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4180
Mailing Address - Country:US
Mailing Address - Phone:970-945-9119
Mailing Address - Fax:970-945-1065
Practice Address - Street 1:2425 GRAND AVE
Practice Address - Street 2:STE 109
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4180
Practice Address - Country:US
Practice Address - Phone:970-945-9119
Practice Address - Fax:970-945-1065
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO74861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice