Provider Demographics
NPI:1215141148
Name:JOHNSON, BRYAN (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19255 SW 65TH AVE
Mailing Address - Street 2:SUITE #230
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7451
Mailing Address - Country:US
Mailing Address - Phone:503-691-9970
Mailing Address - Fax:
Practice Address - Street 1:19255 SW 65TH AVE
Practice Address - Street 2:SUITE #230
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7451
Practice Address - Country:US
Practice Address - Phone:503-691-9970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD74811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics