Provider Demographics
NPI:1235222100
Name:JOHNSON, RICHARD IVAN
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:IVAN
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 1:509 OLIVE WAY
Mailing Address - Street 2:1320
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1720
Mailing Address - Country:US
Mailing Address - Phone:206-622-4066
Mailing Address - Fax:206-623-0646
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:1320
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1720
Practice Address - Country:US
Practice Address - Phone:206-622-4066
Practice Address - Fax:206-623-0646
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00061291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice