Provider Demographics
NPI:1760765770
Name:JOHNSON, JON KELLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:KELLY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1214
Mailing Address - Country:US
Mailing Address - Phone:859-498-7130
Mailing Address - Fax:859-498-7138
Practice Address - Street 1:100 E HIGH ST
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1214
Practice Address - Country:US
Practice Address - Phone:859-498-7130
Practice Address - Fax:859-498-7138
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY70571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60070570Medicaid