Provider Demographics
NPI:1639486590
Name:DARYL L. JOHNSON, DMD, PC
Entity Type:Organization
Organization Name:DARYL L. JOHNSON, DMD, PC
Other - Org Name:MOLALLA FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-829-7677
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-0390
Mailing Address - Country:US
Mailing Address - Phone:503-829-7677
Mailing Address - Fax:503-829-3398
Practice Address - Street 1:128 ROSS ST
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-9390
Practice Address - Country:US
Practice Address - Phone:503-829-7677
Practice Address - Fax:503-829-3398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty