Provider Demographics
NPI:1003900531
Name:JOHNSON, LESLIE G (DDS)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:G
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 1:1025 ROBERTSON STREET
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524
Mailing Address - Country:US
Mailing Address - Phone:970-493-4313
Mailing Address - Fax:970-407-8519
Practice Address - Street 1:1025 ROBERTSON STREET
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524
Practice Address - Country:US
Practice Address - Phone:970-493-4313
Practice Address - Fax:970-407-8519
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9251122300000X
CA027772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist