Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 027772 | CA |
Y | 122300000X | Dentist | 9251 | CO |
NPI | 1003900531 |
---|---|
Provider Name | Leslie G. Johnson |
First Address | Fort Collins, CO 80524 |
Second Address | Fort Collins, CO 80524 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2006 |
Last Update Date | 08/07/2007 |