Provider Demographics
NPI:1972661494
Name:JOHNSON, THEODORE COATANY (DMD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:COATANY
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 1:4855 WARD RD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033
Mailing Address - Country:US
Mailing Address - Phone:303-422-8748
Mailing Address - Fax:303-239-5599
Practice Address - Street 1:4855 WARD RD
Practice Address - Street 2:SUITE 700
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033
Practice Address - Country:US
Practice Address - Phone:303-422-8748
Practice Address - Fax:303-239-5599
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106326122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist