Provider Demographics
NPI:1386625341
Name:JOHNSON, BERNARD JOSEPH (DDS)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:JOSEPH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4368 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2771
Mailing Address - Country:US
Mailing Address - Phone:330-493-4242
Mailing Address - Fax:330-493-1303
Practice Address - Street 1:4368 DRESSLER RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2771
Practice Address - Country:US
Practice Address - Phone:330-493-4242
Practice Address - Fax:330-493-1303
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH136891223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHJO0373893Medicare ID - Type UnspecifiedPROVIDER #