Provider Demographics
NPI:1376718957
Name:TRACY R. JOHNSON, DDS, PS
Entity Type:Organization
Organization Name:TRACY R. JOHNSON, DDS, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-895-8841
Mailing Address - Street 1:3377 BETHEL RD SE STE 107
Mailing Address - Street 2:PMB 184
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-5608
Mailing Address - Country:US
Mailing Address - Phone:360-895-8841
Mailing Address - Fax:360-895-9350
Practice Address - Street 1:2040 MITCHELL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4401
Practice Address - Country:US
Practice Address - Phone:360-895-8841
Practice Address - Fax:360-895-9350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000089611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty