Healthcare Provider Details

I. General information

NPI: 1366456857
Provider Name (Legal Business Name): ROBERT D JOHNSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 SW COURT AVE
PENDLETON OR
97801-1910
US

IV. Provider business mailing address

809 SW COURT AVE
PENDLETON OR
97801-1910
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-3241
  • Fax: 541-276-6423
Mailing address:
  • Phone: 541-276-3241
  • Fax: 541-276-6423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD4948
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: