Provider Demographics
NPI:1962717520
Name:BRYAN C JOHNSON DMD PC
Entity type:Organization
Organization Name:BRYAN C JOHNSON DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-225-5600
Mailing Address - Street 1:500 COLUMBIA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:WOODLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98674-8491
Mailing Address - Country:US
Mailing Address - Phone:360-225-5600
Mailing Address - Fax:360-225-0369
Practice Address - Street 1:500 COLUMBIA ST
Practice Address - Street 2:SUITE B
Practice Address - City:WOODLAND
Practice Address - State:WA
Practice Address - Zip Code:98674-8491
Practice Address - Country:US
Practice Address - Phone:360-225-5600
Practice Address - Fax:360-225-0369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA8734261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental