Provider Demographics
NPI:1699451203
Name:JOHNSTON, BRADY MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:MICHAEL
Last Name:JOHNSTON
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 1:3845 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1109
Mailing Address - Country:US
Mailing Address - Phone:770-727-4470
Mailing Address - Fax:
Practice Address - Street 1:3845 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1109
Practice Address - Country:US
Practice Address - Phone:770-727-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1230761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice