Provider Demographics
NPI:1649467184
Name:JOHNSON, ROBERT H (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:H
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 1:670 SUPERIOR CT STE 101
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6179
Mailing Address - Country:US
Mailing Address - Phone:541-779-6170
Mailing Address - Fax:541-779-0989
Practice Address - Street 1:670 SUPERIOR CT STE 101
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6179
Practice Address - Country:US
Practice Address - Phone:541-779-6170
Practice Address - Fax:541-779-0989
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3417859922122300000X
ORD95691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist