Provider Demographics
NPI:1508936998
Name:NIETO, JOHANA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHANA
Middle Name:
Last Name:NIETO
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 1:800 W BROAD ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3142
Mailing Address - Country:US
Mailing Address - Phone:703-237-3516
Mailing Address - Fax:
Practice Address - Street 1:800 W BROAD ST
Practice Address - Street 2:SUITE 304
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3106
Practice Address - Country:US
Practice Address - Phone:703-237-3516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014112191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice