Provider Demographics
NPI:1003822933
Name:JOHNSON, PENNY LEE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11281 SE STEVENS RD APT 203
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-8314
Mailing Address - Country:US
Mailing Address - Phone:503-481-8240
Mailing Address - Fax:
Practice Address - Street 1:11281 SE STEVENS RD APT 203
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-8314
Practice Address - Country:US
Practice Address - Phone:503-481-8240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0883124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist