Provider Demographics
NPI:1902420318
Name:JOHNSON, CORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:
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 1:170 E COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 E COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-2712
Practice Address - Country:US
Practice Address - Phone:719-660-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11774185-0702122300000X
UT11774185-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist