Provider Demographics
NPI:1346565165
Name:PLJ PC
Entity Type:Organization
Organization Name:PLJ PC
Other - Org Name:DR. KEVIN B. JOHNSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-266-2705
Mailing Address - Street 1:333 NW 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3602
Mailing Address - Country:US
Mailing Address - Phone:503-266-2705
Mailing Address - Fax:503-266-2973
Practice Address - Street 1:333 NW 3RD AVE
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3602
Practice Address - Country:US
Practice Address - Phone:503-266-2705
Practice Address - Fax:503-266-2973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9406122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty