Provider Demographics
NPI:1942364575
Name:JOHNSON, KEVIN BROOKS (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BROOKS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 NW 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3602
Mailing Address - Country:US
Mailing Address - Phone:503-266-2705
Mailing Address - Fax:503-266-2973
Practice Address - Street 1:333 NW 3RD AVE
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3602
Practice Address - Country:US
Practice Address - Phone:503-266-2705
Practice Address - Fax:503-266-2973
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010704122300000X
ORD9406122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist