Healthcare Provider Details

I. General information

NPI: 1952494676
Provider Name (Legal Business Name): CARL KENNETH JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S CARR RD #300
RENTON WA
98055-5840
US

IV. Provider business mailing address

601 S. CARR RD #300
RENTON WA
98055-5840
US

V. Phone/Fax

Practice location:
  • Phone: 425-277-1844
  • Fax: 425-271-6766
Mailing address:
  • Phone: 425-277-1844
  • Fax: 425-271-6766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number6475
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: