Provider Demographics
NPI:1811364136
Name:MCCOY, JOHANNA (RDH)
Entity type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 ROEHL RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6731
Mailing Address - Country:US
Mailing Address - Phone:505-377-0298
Mailing Address - Fax:
Practice Address - Street 1:4400 CUTLER AVENUE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-881-1243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH3209124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist