Provider Demographics
NPI:1366591273
Name:JOHNSON, DARYL L (DMD)
Entity type:Individual
Prefix:DR
First Name:DARYL
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-0390
Mailing Address - Country:US
Mailing Address - Phone:503-829-7677
Mailing Address - Fax:503-829-3398
Practice Address - Street 1:128 ROSS ST
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-9390
Practice Address - Country:US
Practice Address - Phone:503-829-7677
Practice Address - Fax:503-829-3398
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD6951OtherSTATE LICENSE
OR93-1306543OtherFEIN