Provider Demographics
NPI:1750638284
Name:JOHNSON, COLE JEROME (DDS)
Entity Type:Individual
Prefix:DR
First Name:COLE
Middle Name:JEROME
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 1:2420 S 51ST CT STE A
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3669
Mailing Address - Country:US
Mailing Address - Phone:479-452-2995
Mailing Address - Fax:
Practice Address - Street 1:2420 S 51ST CT STE A
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3669
Practice Address - Country:US
Practice Address - Phone:479-452-2995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR38671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice