Healthcare Provider Details

I. General information

NPI: 1134143076
Provider Name (Legal Business Name): ROD JOHNSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11815 SW KING JAMES PL STE 10
TIGARD OR
97224-2479
US

IV. Provider business mailing address

11815 SW KING JAMES PL STE 10
TIGARD OR
97224-2479
US

V. Phone/Fax

Practice location:
  • Phone: 503-968-6101
  • Fax: 503-968-6717
Mailing address:
  • Phone: 503-968-6101
  • Fax: 503-968-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD7075
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: