Mary Beth Johnson, DDS
Individual provider Active NPI General Practice Dentistry · Polacca, AZ
NPI 1437292570 · NPPES record last updated Jun 26, 2009
Key facts
- NPI
- 1437292570
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- 30020478 (OH)
- Practice address
- Hwy 264, MP 388
Polacca, AZ 86042 - Phone
- (928) 737-6162
- NPI assigned
- Feb 15, 2007
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20171108002878 | TX | Practitioner - Oral Surgery | 3779849633 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 30020478 | OH | MD | General Practice Dentistry |
| 30-020478 | OH | MD | Pediatric Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Tuba City Regional Health Care Corporation | General Practice | Current | Accepting new patients |
| Lechee Health Facility | Current |
Accepting new patients | |
| Tuba City Regional Health Care Corporation | Current |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 30020478 | OH | Yes |
| Pediatric Dentistry | 1223P0221X | 30-020478 | OH |
Addresses
Primary practice location
Hwy 264, MP 388
Polacca, AZ 86042
Mailing address
Hopi Health Care Center Keams Canyon S.U.
PO Box 4000
Polacca, AZ 86042
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 420456 | Medicaid | AZ |
Other providers in Polacca, AZ
- Jacqueline Hughes
- Walema Ignacio
- Gerhard Heinz Jakubowski
- Derek Phillip James
- Daniel Jenkins
- Nicole Jojola
- Andrea Lynn Joshevama
- Carletta J Joshevama
- Zainab Khatoon
- Gina Marie Kosek
All providers in Polacca, AZ · General Practice Dentistry in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 26, 2009. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.