Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | DE00006627 | WA |
NPI | 1629011069 |
---|---|
Provider Name | Dr. Bruce Roy Johnson |
First Address | Puyallup, WA 98375-9682 |
Second Address | Tacoma, WA 98404-4922 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0149889 | LABOR & INDUSTRIES (01) | WA |
91111635510 | KITSAP PHYSICIAN SERVICE (01) | VA |
JO6014 | REGENCE (01) | WA |