Provider Demographics
NPI:1073821286
Name:JOHNSON, BENJAMIN REED (DMD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:REED
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S CARR RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5866
Mailing Address - Country:US
Mailing Address - Phone:425-466-1185
Mailing Address - Fax:
Practice Address - Street 1:601 S CARR RD
Practice Address - Street 2:SUITE 300
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5866
Practice Address - Country:US
Practice Address - Phone:425-466-1185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0284131223G0001X
WA602045501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice