Provider Demographics
NPI:1932624178
Name:JOHNSON, JESSE (DDS)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 EAGLE RANCH RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114
Mailing Address - Country:US
Mailing Address - Phone:505-553-3607
Mailing Address - Fax:505-890-2949
Practice Address - Street 1:9201 EAGLE RANCH RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-6032
Practice Address - Country:US
Practice Address - Phone:505-553-3607
Practice Address - Fax:505-890-2949
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000000Medicaid