Provider Demographics
NPI:1407908742
Name:JOHNSON, JOLLY SAMUEL (DDS)
Entity Type:Individual
Prefix:
First Name:JOLLY
Middle Name:SAMUEL
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 1:2132 E HARMONY RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-9504
Mailing Address - Country:US
Mailing Address - Phone:970-287-3701
Mailing Address - Fax:970-287-3702
Practice Address - Street 1:2132 E HARMONY RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-9504
Practice Address - Country:US
Practice Address - Phone:970-287-3701
Practice Address - Fax:970-287-3702
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO91121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57683255Medicaid