Healthcare Provider Details

I. General information

NPI: 1740384981
Provider Name (Legal Business Name): BRYAN J JOHNSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 PONTIAC LAKE RD SUITE B
WATERFORD MI
48328-1281
US

IV. Provider business mailing address

11525 HIGHLAND RD SUITE 23
HARTLAND MI
48353-2726
US

V. Phone/Fax

Practice location:
  • Phone: 248-674-0303
  • Fax: 248-674-2947
Mailing address:
  • Phone: 810-632-0303
  • Fax: 810-632-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberBJ017615
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberBJ017615
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: