Provider Demographics
NPI:1790540482
Name:JOHNSON, SARA LUE
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:LUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N BEAVER ST BLDG 2
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3145
Mailing Address - Country:US
Mailing Address - Phone:206-543-6365
Mailing Address - Fax:
Practice Address - Street 1:710 N BEAVER ST BLDG 2
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3145
Practice Address - Country:US
Practice Address - Phone:206-543-6365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0122391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice