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General NPI Number Information
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NPI Number | 1376718957
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Entity Type | Organization
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Legal Business Name | TRACY R. JOHNSON, DDS, PS
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Dates
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Enumeration Date | 04/24/2008
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Last Update Date | 04/24/2008
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Provider Practice Location Address
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Address Line | 2040 MITCHELL RD SE
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City | PORT ORCHARD
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State | WA
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Zip | 98366-4401
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Country | US
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Telephone | 360-895-8841
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Fax | 360-895-9350
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Provider Business Mailing Address
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Address Line | 3377 BETHEL RD SE STE 107 PMB 184
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City | PORT ORCHARD
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State | WA
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Zip | 98366-5608
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Country | US
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Telephone | 360-895-8841
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Fax | 360-895-9350
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. TRACY R JOHNSON
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Credential | DDS
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Telephone | 360-895-8841
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DE00008961
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License Number State | WA
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