Provider Demographics
NPI:1699304519
Name:JOHNSON, BRYAN EUGENE (DMD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:EUGENE
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:PSC 819 BOX 18
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09645-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HOSPITAL AMERICANO; BASE NAVAL DE ROTA
Practice Address - Street 2:APARTADO DE CORREOS 33
Practice Address - City:ROTA
Practice Address - State:CADIZ
Practice Address - Zip Code:11530
Practice Address - Country:ES
Practice Address - Phone:956-823-3733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11945122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes122300000XDental ProvidersDentist