Provider Demographics
NPI:1366456857
Name:JOHNSON, ROBERT D (DMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
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 1:809 SW COURT AVE
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-1910
Mailing Address - Country:US
Mailing Address - Phone:541-276-3241
Mailing Address - Fax:541-276-6423
Practice Address - Street 1:809 SW COURT AVE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-1910
Practice Address - Country:US
Practice Address - Phone:541-276-3241
Practice Address - Fax:541-276-6423
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD49481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice