Provider Demographics
NPI:1548241219
Name:JOHNSON, TRACY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:9101 BRIDGEPORT WAY SW
Mailing Address - Street 2:BLDG B2
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2419
Mailing Address - Country:US
Mailing Address - Phone:253-584-0858
Mailing Address - Fax:253-584-1446
Practice Address - Street 1:9101 BRIDGEPORT WAY SW
Practice Address - Street 2:BLDG B2
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2419
Practice Address - Country:US
Practice Address - Phone:253-584-0858
Practice Address - Fax:253-584-1446
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2022-01-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TX136381223S0112X
WADE000089611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery