Healthcare Provider Details

I. General information

NPI: 1336190099
Provider Name (Legal Business Name): RYAN MAX JOHNSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7451 N BEACH ST STE 140
FORT WORTH TX
76137-5160
US

IV. Provider business mailing address

113 SCENIC RIDGE DR
WEATHERFORD TX
76087-1522
US

V. Phone/Fax

Practice location:
  • Phone: 817-847-7001
  • Fax:
Mailing address:
  • Phone: 702-299-5821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22989
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22989
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22989
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5948521-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: