Provider Demographics
NPI:1740600105
Name:JOHNSON, NICOLE (DDS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1600 W LANE AVE UNIT 310
Mailing Address - Street 2:
Mailing Address - City:UPPER ARLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43221-3966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 W LANE AVE UNIT 310
Practice Address - Street 2:
Practice Address - City:UPPER ARLINGTON
Practice Address - State:OH
Practice Address - Zip Code:43221-3966
Practice Address - Country:US
Practice Address - Phone:847-401-0182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.0243011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program