Provider Demographics
NPI:1225559818
Name:JESSICA M JOHNSON DDS PA
Entity Type:Organization
Organization Name:JESSICA M JOHNSON DDS PA
Other - Org Name:OTTAWA KANSAS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:785-766-1031
Mailing Address - Street 1:1334 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067-3527
Mailing Address - Country:US
Mailing Address - Phone:785-242-5753
Mailing Address - Fax:
Practice Address - Street 1:1334 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-3527
Practice Address - Country:US
Practice Address - Phone:785-242-5753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS610011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS61001OtherLICENSE NUMBER