Provider Demographics
NPI:1114140712
Name:JOHNSON, JEFFREY
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5611 119TH AVE SE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-3799
Mailing Address - Country:US
Mailing Address - Phone:425-644-0300
Mailing Address - Fax:425-643-8394
Practice Address - Street 1:5611 119TH AVE SE
Practice Address - Street 2:SUITE 5
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-3799
Practice Address - Country:US
Practice Address - Phone:425-644-0300
Practice Address - Fax:425-643-8394
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5715122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist