Kissendrah Sue Johnson
Individual provider Active NPI Dentist · Isleta, NM
NPI 1124502984 · NPPES record last updated Sep 18, 2018
Key facts
- NPI
- 1124502984
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- DD4977 (NM)
- Practice address
- 01 Sagebrush Street
Isleta, NM 87022 - Phone
- (505) 869-4866
- Fax
- (502) 869-4881
- NPI assigned
- Sep 18, 2018
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DD4977 | NM | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Pueblo of Isleta | Past | Accepting new patients | |
| Pueblo of Isleta | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | DD4977 | NM | Yes |
Addresses
Primary practice location
01 Sagebrush Street
Isleta, NM 87022
Mailing address
PO Box 640
Isleta, NM 87022-0640
Phone (505) 869-3200
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| DD4977 | Other | NM | LICENSE |
Other providers in Isleta, NM
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 18, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.