Provider Demographics
NPI:1154825503
Name:JOHNSON, ROBERT EDWARD III (DMD, MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:III
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 OLIVE WAY STE #750
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101
Mailing Address - Country:US
Mailing Address - Phone:206-343-7500
Mailing Address - Fax:
Practice Address - Street 1:509 OLIVE WAY STE 750
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1773
Practice Address - Country:US
Practice Address - Phone:206-343-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WADE60978946204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program