Provider Demographics
NPI:1851546642
Name:JOHNSON, ROBERT EDWARD JR (DDS, FAGD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:DDS, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 OLIVE WAY
Mailing Address - Street 2:1149
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1779
Mailing Address - Country:US
Mailing Address - Phone:206-682-3888
Mailing Address - Fax:206-682-1694
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:1149
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1720
Practice Address - Country:US
Practice Address - Phone:206-682-3888
Practice Address - Fax:206-682-1694
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005842122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist