MEDICARE: RYAN DARREN JOHNSON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12103826-9923	UT
2	390200000X	Student in an Organized Health Care Education/Training Program		NM
3	390200000X	Student in an Organized Health Care Education/Training Program	TD-00-131	NM
4	1223P0300X	Periodontics	10576	KY

General Provider Information

NPI Number	:	1659991370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN DARREN JOHNSON DMD

Provider Business Mailing Address
First Line	:	6704 SUMAC RIDGE DR
Second Line	:
City	:	CRESTWOOD
State	:	KY
Zip	:	40014-9324
Country	:	US
Telephone Number	:	505-925-4031
Fax Number	:	505-925-4030

Provider Business Practice Location Address
First Line	:	6704 SUMAC RIDGE DR
Second Line	:
City	:	CRESTWOOD
State	:	KY
Zip	:	40014-9324
Country	:	US
Telephone Number	:	505-925-4031
Fax Number	:	505-925-4030

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2020
Last Update Date	:	07/09/2021

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