Provider Demographics
NPI:1558961037
Name:JOHNSON, DEAN (LAC)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 NW 5TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4895
Mailing Address - Country:US
Mailing Address - Phone:541-753-5152
Mailing Address - Fax:
Practice Address - Street 1:310 NW 5TH ST STE 201
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4895
Practice Address - Country:US
Practice Address - Phone:541-753-5152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00191171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORAC00191OtherACUPUNCTURE LICENSE