Provider Demographics
NPI:1053605246
Name:JOHNSON, COLE R (DMD)
Entity type:Individual
Prefix:DR
First Name:COLE
Middle Name:R
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 1:2755 COMMERCIAL ST SE STE 200
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4991
Mailing Address - Country:US
Mailing Address - Phone:503-967-6665
Mailing Address - Fax:503-385-8471
Practice Address - Street 1:2755 COMMERCIAL ST SE STE 200
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4991
Practice Address - Country:US
Practice Address - Phone:503-967-6665
Practice Address - Fax:503-385-8471
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-05
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD95271223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics