Healthcare Provider Details

I. General information

NPI: 1407427024
Provider Name (Legal Business Name): BRADLEY SCOTT JOHNSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 MAIN ST
CONWAY SC
29526-3333
US

IV. Provider business mailing address

1906 MAIN ST
CONWAY SC
29526-3333
US

V. Phone/Fax

Practice location:
  • Phone: 843-248-3843
  • Fax:
Mailing address:
  • Phone: 843-248-3843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9917
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number38896
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: