1528855830 NPI number — PAGOSA SPRINGS FAMILY DENTAL LLC

Table of content: DR. DONNA R. JOHNSON PH.D. (NPI 1265567929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528855830 NPI number — PAGOSA SPRINGS FAMILY DENTAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAGOSA SPRINGS FAMILY DENTAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528855830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 PINES CLUB PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAGOSA SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81147-9304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-565-0609
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2363 EAGLE DR UNIT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAGOSA SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81147-9058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-565-0609
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/21/2025

Additional Information

Authorized Official

Authorized Official Last Name:
NYLUND
Authorized Official First Name:
JUSTIN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-565-0609

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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