Provider Demographics
NPI:1013049006
Name:JOHNSON, BROCK JONATHAN (DDS)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:JONATHAN
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 1:615 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:CO
Mailing Address - Zip Code:80759-2713
Mailing Address - Country:US
Mailing Address - Phone:970-848-0960
Mailing Address - Fax:
Practice Address - Street 1:900 S. ASH ST.
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:CO
Practice Address - Zip Code:80759
Practice Address - Country:US
Practice Address - Phone:970-848-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9241122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist