MEDICARE: DR. ROGER DALE JOHNSON D.D.S.

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	122300000X	Dentist	4872	WA

General Provider Information

NPI Number	:	1740286442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER DALE JOHNSON D.D.S.

Provider Business Mailing Address
First Line	:	7525 PIONEER WAY
Second Line	:	STE 102
City	:	GIG HARBOR
State	:	WA
Zip	:	98335-1165
Country	:	US
Telephone Number	:	253-851-9963
Fax Number	:	253-858-2425

Provider Business Practice Location Address
First Line	:	7525 PIONEER WAY
Second Line	:	STE 102
City	:	GIG HARBOR
State	:	WA
Zip	:	98335-1165
Country	:	US
Telephone Number	:	253-851-9963
Fax Number	:	253-858-2425

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	07/08/2007

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