MEDICARE: DR. KENNETH GEORGE JOHNSEN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4165	WA

General Provider Information

NPI Number	:	1134204811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH GEORGE JOHNSEN DDS

Provider Business Mailing Address
First Line	:	314 FOURTH AVENUE SOUTH
Second Line	:
City	:	KENT
State	:	WA
Zip	:	98032-5836
Country	:	US
Telephone Number	:	253-859-2111
Fax Number	:

Provider Business Practice Location Address
First Line	:	314 FOURTH AVENUE SOUTH
Second Line	:
City	:	KENT
State	:	WA
Zip	:	98032-5836
Country	:	US
Telephone Number	:	253-859-2111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	07/08/2007

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