Provider Demographics
NPI:1427318427
Name:JOHNSON, NATHAN L (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 W 6TH AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2770
Mailing Address - Country:US
Mailing Address - Phone:509-838-4321
Mailing Address - Fax:
Practice Address - Street 1:508 W 6TH AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2770
Practice Address - Country:US
Practice Address - Phone:509-838-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2016-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60569432122300000X
KY91851223G0001X
UT8303527-9923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice