=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740553106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGEPORT FAMILY DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2012
-----------------------------------------------------
Last Update Date | 02/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7420 SW BRIDGEPORT RD STE 104
-----------------------------------------------------
City | TIGARD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97224-7790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-430-7909
-----------------------------------------------------
Fax | 503-268-1501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7420 SW BRIDGEPORT RD STE 104
-----------------------------------------------------
City | TIGARD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97224-7790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-430-7909
-----------------------------------------------------
Fax | 503-268-1501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. KELLY JEAN JOHNSON
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 503-430-7909
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D7482
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------