1124375423 NPI number — DR. GLEN HOWARD JOHNSON DDS, MS

Table of content: DR. GLEN HOWARD JOHNSON DDS, MS (NPI 1124375423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124375423 NPI number — DR. GLEN HOWARD JOHNSON DDS, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
GLEN
Provider Middle Name:
HOWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS, MS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124375423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BOX 357456, DEPARTMENT OF RESTORATIVE DENTISTRY
Provider Second Line Business Mailing Address:
UNIVERSITY OF WASHINGTON
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98195-7456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-543-5948
Provider Business Mailing Address Fax Number:
206-543-7783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
UNIVERSITY OF WASHINGTON SCHOOL OF DENTISTRY
Provider Second Line Business Practice Location Address:
RESTORATIVE DENTISTRY BOX 357456
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98195-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-543-5948
Provider Business Practice Location Address Fax Number:
206-543-7783
Provider Enumeration Date:
08/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  5146 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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