Provider Demographics
NPI:1376651364
Name:JOHNSON, JEREMY LEONARD (DDS)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:LEONARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14650 N KELSEY ST #104-105
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272
Mailing Address - Country:US
Mailing Address - Phone:360-794-8580
Mailing Address - Fax:844-470-1798
Practice Address - Street 1:14650 N KELSEY ST # 104-105
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1456
Practice Address - Country:US
Practice Address - Phone:360-794-8580
Practice Address - Fax:844-470-1798
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009214122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist