Provider Demographics
NPI:1710973151
Name:JOHNSON, RICHARD L (DMD PC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11565 SW HALL BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8493
Mailing Address - Country:US
Mailing Address - Phone:503-620-2131
Mailing Address - Fax:503-620-0505
Practice Address - Street 1:11565 SW HALL BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8493
Practice Address - Country:US
Practice Address - Phone:503-620-2131
Practice Address - Fax:503-620-0505
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5430122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist