Healthcare Provider Details

I. General information

NPI: 1629011069
Provider Name (Legal Business Name): BRUCE ROY JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 E 32ND ST
TACOMA WA
98404-4922
US

IV. Provider business mailing address

17308 97TH AVENUE CT E
PUYALLUP WA
98375-9682
US

V. Phone/Fax

Practice location:
  • Phone: 253-593-0232
  • Fax:
Mailing address:
  • Phone: 253-840-5462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDE00006627
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: