Provider Demographics
NPI:1437292570
Name:JOHNSON, MARY BETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:BETH
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:HOPI HEALTH CARE CENTER KEAMS CANYON S.U.
Mailing Address - Street 2:PO BOX 4000
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HWY 264, MP 388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-6162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300204781223G0001X
OH30-0204781223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ420456Medicaid