Provider Demographics
NPI:1922119189
Name:JOHNSON, JEREMIAH O (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:O
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N. EMERSON AVE
Mailing Address - Street 2:SUITE #101
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801
Mailing Address - Country:US
Mailing Address - Phone:509-663-0068
Mailing Address - Fax:509-663-0060
Practice Address - Street 1:304 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2107
Practice Address - Country:US
Practice Address - Phone:509-663-0068
Practice Address - Fax:509-663-0060
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603374521223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2036913Medicaid