Healthcare Provider Details

I. General information

NPI: 1346565165
Provider Name (Legal Business Name): PLJ PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 NW 3RD AVE
CANBY OR
97013-3602
US

IV. Provider business mailing address

333 NW 3RD AVE
CANBY OR
97013-3602
US

V. Phone/Fax

Practice location:
  • Phone: 503-266-2705
  • Fax: 503-266-2973
Mailing address:
  • Phone: 503-266-2705
  • Fax: 503-266-2973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD9406
License Number StateOR

VIII. Authorized Official

Name: DR. KEVIN BROOKS JOHNSON
Title or Position: OWNER
Credential: DMD
Phone: 503-266-2705