Provider Demographics
NPI:1124242813
Name:JOHNSON, DENNIS DOUGLAS (DMD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:DOUGLAS
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 1:410 LANCASTER DR NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4794
Mailing Address - Country:US
Mailing Address - Phone:503-581-9419
Mailing Address - Fax:503-581-0438
Practice Address - Street 1:410 LANCASTER DR NE
Practice Address - Street 2:SUITE A
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4794
Practice Address - Country:US
Practice Address - Phone:503-581-9419
Practice Address - Fax:503-581-0438
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD48391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR14097-0Medicaid
OR14097-0Medicaid