Individual
DR. KELLY WADE JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DDS
Contact information
Practice address
2815 S PENNSYLVANIA AVE, #203, LANSING, MI 48910-3495
(517) 272-4150
Mailing address
5303 S CEDAR ST, LANSING, MI 48911-3800
(517) 272-4150
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
2901018145
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1385419
UNITED CONCORDIA
MI
01
—
161661900
DELTA DENTAL
MI
05
—
4530810
—
MI
Enumeration date
01/12/2006
Last updated
09/10/2015
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