Provider Demographics
NPI:1922212943
Name:COLLIS JOHNSON JR DDS PC
Entity Type:Organization
Organization Name:COLLIS JOHNSON JR DDS PC
Other - Org Name:FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST OWNER PC
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-322-1177
Mailing Address - Street 1:1756 VINE ST
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 1:1756 VINE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206
Practice Address - Country:US
Practice Address - Phone:303-322-1177
Practice Address - Fax:303-322-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104176122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1831291855OtherNATIONAL PROVIDER TYPEI
CO02014769Medicaid
CO=========OtherTIN NUMBER