Healthcare Provider Details

I. General information

NPI: 1447924808
Provider Name (Legal Business Name): RYAN JOHNSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 OAKBROOK CTR STE 714
OAK BROOK IL
60523-1831
US

IV. Provider business mailing address

958 KENSINGTON DR
NORTHBROOK IL
60062-5975
US

V. Phone/Fax

Practice location:
  • Phone: 630-654-3331
  • Fax: 630-954-2910
Mailing address:
  • Phone: 941-914-5056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021.003528
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: