Provider Demographics
NPI:1811914344
Name:JOHNSON, MICHAEL WALTER (MD & DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WALTER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD & DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 SUTTLE ST
Mailing Address - Street 2:S# E
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-6829
Mailing Address - Country:US
Mailing Address - Phone:970-385-5432
Mailing Address - Fax:970-385-5077
Practice Address - Street 1:72 SUTTLE ST
Practice Address - Street 2:S# E
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-6829
Practice Address - Country:US
Practice Address - Phone:970-385-5432
Practice Address - Fax:970-385-5077
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO363351223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G87185Medicare UPIN
C46741Medicare ID - Type Unspecified