Provider Demographics
NPI:1154601839
Name:JOHNSON, BRADLEY R (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 STERNBERG AVE
Mailing Address - Street 2:HQ US ARMY DENTAL ACTIVITY
Mailing Address - City:FORT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-1526
Mailing Address - Country:US
Mailing Address - Phone:757-314-7944
Mailing Address - Fax:757-314-7942
Practice Address - Street 1:7288 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-7578
Practice Address - Country:US
Practice Address - Phone:440-946-0088
Practice Address - Fax:757-314-7942
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413320122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist