Provider Demographics
NPI:1679782973
Name:JOHNSON, RICHARD C (LD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 6TH AVE
Mailing Address - Street 2:STE A
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-4938
Mailing Address - Country:US
Mailing Address - Phone:253-752-1320
Mailing Address - Fax:253-752-1425
Practice Address - Street 1:3720 6TH AVE
Practice Address - Street 2:STE A
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-4938
Practice Address - Country:US
Practice Address - Phone:253-752-1320
Practice Address - Fax:253-752-1425
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA416122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5042817Medicaid