Provider Demographics
NPI:1457040693
Name:JOHNSON, KASSANDRA LORENA
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:LORENA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASSANDRA
Other - Middle Name:LORENA
Other - Last Name:COSTABEL-MONSALVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8035 ELEMENT CIR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-3375
Mailing Address - Country:US
Mailing Address - Phone:919-824-8426
Mailing Address - Fax:
Practice Address - Street 1:320 NORTHEAST BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2424
Practice Address - Country:US
Practice Address - Phone:910-596-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC143031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice