Provider Demographics
NPI:1952494676
Name:JOHNSON, CARL KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:KENNETH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:601 S. CARR RD
Mailing Address - Street 2:#300
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5840
Mailing Address - Country:US
Mailing Address - Phone:425-277-1844
Mailing Address - Fax:425-271-6766
Practice Address - Street 1:601 S CARR RD
Practice Address - Street 2:#300
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5840
Practice Address - Country:US
Practice Address - Phone:425-277-1844
Practice Address - Fax:425-271-6766
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA64751223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA911646137Medicare UPIN