Individual
KISSENDRAH SUE JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
01 SAGEBRUSH STREET, ISLETA, NM 87022
(505) 869-4866
(502) 869-4881
Mailing address
PO BOX 640, ISLETA, NM 87022-0640
(505) 869-3200
(505) 869-4881
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DD4977
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DD4977
LICENSE
NM
Enumeration date
09/18/2018
Last updated
09/18/2018
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