Healthcare Provider Details

I. General information

NPI: 1174851596
Provider Name (Legal Business Name): JERROLD STUART JOHNSON DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3511 BUCKLIN HILL RD. NW
SILVERDALE WA
98383
US

IV. Provider business mailing address

3511 NW BUCKLIN HILL ROAD
SILVERDALE WA
98383
US

V. Phone/Fax

Practice location:
  • Phone: 360-337-2020
  • Fax: 360-337-2021
Mailing address:
  • Phone: 360-337-2020
  • Fax: 360-337-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE00009912
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: