Provider Demographics
NPI:1770348401
Name:JOHNSTOWN PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:JOHNSTOWN PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-806-1664
Mailing Address - Street 1:257 JOHNSTOWN CENTER DR UNIT 107
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-7847
Mailing Address - Country:US
Mailing Address - Phone:816-806-1664
Mailing Address - Fax:
Practice Address - Street 1:257 JOHNSTOWN CENTER DR UNIT 107
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-7847
Practice Address - Country:US
Practice Address - Phone:816-806-1664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty