Provider Demographics
NPI:1053153171
Name:JOHNSON, GORDON MACDONALD (LD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:MACDONALD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GILKEY RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-2822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 GILKEY RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-2822
Practice Address - Country:US
Practice Address - Phone:360-757-4909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist