Provider Demographics
NPI:1508958281
Name:JOHNSON, GLENN EVERETT (DDS)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:EVERETT
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 1:2478 PATTERSON ROAD
Mailing Address - Street 2:SUITE 24
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505
Mailing Address - Country:US
Mailing Address - Phone:970-242-9207
Mailing Address - Fax:970-256-1640
Practice Address - Street 1:2478 PATTERSON ROAD
Practice Address - Street 2:SUITE 24
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505
Practice Address - Country:US
Practice Address - Phone:970-242-9207
Practice Address - Fax:970-242-9207
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7492122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist