Provider Demographics
NPI:1013168103
Name:JEFF JOHNSTON
Entity type:Organization
Organization Name:JEFF JOHNSTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-975-6987
Mailing Address - Street 1:3600 E ALAMEDA AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-3190
Mailing Address - Country:US
Mailing Address - Phone:303-975-6987
Mailing Address - Fax:303-975-6988
Practice Address - Street 1:3600 E ALAMEDA AVE STE 220
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-3190
Practice Address - Country:US
Practice Address - Phone:303-975-6987
Practice Address - Fax:303-975-6988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO90961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22270337Medicaid