Provider Demographics
NPI:1740286442
Name:JOHNSON, ROGER DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DALE
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 1:7525 PIONEER WAY
Mailing Address - Street 2:STE 102
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1165
Mailing Address - Country:US
Mailing Address - Phone:253-851-9963
Mailing Address - Fax:253-858-2425
Practice Address - Street 1:7525 PIONEER WAY
Practice Address - Street 2:STE 102
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1165
Practice Address - Country:US
Practice Address - Phone:253-851-9963
Practice Address - Fax:253-858-2425
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4872122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist