MEDICARE: DR. TYRAN ERIC JOHNSON D.D.S.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	021002224	IL

General Provider Information

NPI Number	:	1770671414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TYRAN ERIC JOHNSON D.D.S.

Provider Business Mailing Address
First Line	:	9240 BROADWAY AVE
Second Line	:
City	:	BROOKFIELD
State	:	IL
Zip	:	60513-1252
Country	:	US
Telephone Number	:	708-680-7017
Fax Number	:	708-419-3537

Provider Business Practice Location Address
First Line	:	9240 BROADWAY AVE
Second Line	:
City	:	BROOKFIELD
State	:	IL
Zip	:	60513-1252
Country	:	US
Telephone Number	:	708-680-7017
Fax Number	:	708-419-3537

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	12/23/2022

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