Provider Demographics
NPI:1467431932
Name:JOHNSON, KELLY WADE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:WADE
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 1:5303 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-3800
Mailing Address - Country:US
Mailing Address - Phone:517-272-4150
Mailing Address - Fax:
Practice Address - Street 1:2815 S PENNSYLVANIA AVE
Practice Address - Street 2:#203
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3495
Practice Address - Country:US
Practice Address - Phone:517-272-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010181451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1385419OtherUNITED CONCORDIA
MI161661900OtherDELTA DENTAL
MI161661900OtherBLUE CROSS BLUE SHIELD
MI4530810Medicaid