Provider Demographics
NPI:1821346206
Name:JOHNSON, JUANITA LEE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:JUANITA
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MISS
Other - First Name:JUANITA
Other - Middle Name:LEE
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:PO BOX 3894
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98089-0394
Mailing Address - Country:US
Mailing Address - Phone:206-250-1784
Mailing Address - Fax:206-878-0813
Practice Address - Street 1:22831 26TH AVE S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-7115
Practice Address - Country:US
Practice Address - Phone:206-250-1784
Practice Address - Fax:206-878-0813
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00002159124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist