Provider Demographics
NPI:1437486800
Name:JOHNSON, KELLY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 SW BRIDGEPORT RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7790
Mailing Address - Country:US
Mailing Address - Phone:503-430-7909
Mailing Address - Fax:503-268-1501
Practice Address - Street 1:7420 SW BRIDGEPORT RD
Practice Address - Street 2:SUITE 104
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7790
Practice Address - Country:US
Practice Address - Phone:503-430-7909
Practice Address - Fax:503-268-1501
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD74821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice