Provider Demographics
NPI:1831291855
Name:JOHNSON, COLLIS JR (DDS)
Entity Type:Individual
Prefix:
First Name:COLLIS
Middle Name:
Last Name:JOHNSON
Suffix:JR
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 1:1756 VINE STREET
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206
Mailing Address - Country:US
Mailing Address - Phone:303-322-1177
Mailing Address - Fax:303-322-1199
Practice Address - Street 1:13065 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2532
Practice Address - Country:US
Practice Address - Phone:303-724-7073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO014761223E0200X
CO041761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02014769Medicaid