Healthcare Provider Details

I. General information

NPI: 1639486590
Provider Name (Legal Business Name): DARYL L. JOHNSON, DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 ROSS ST
MOLALLA OR
97038-9390
US

IV. Provider business mailing address

PO BOX 390
MOLALLA OR
97038-0390
US

V. Phone/Fax

Practice location:
  • Phone: 503-829-7677
  • Fax: 503-829-3398
Mailing address:
  • Phone: 503-829-7677
  • Fax: 503-829-3398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD6951
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. TARA JOHNSON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 503-829-7677