Provider Demographics
NPI:1013034933
Name:JOHNSON, BRUCE LYMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LYMAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 CASTLE HEIGHTS CT
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2670
Mailing Address - Country:US
Mailing Address - Phone:615-444-0065
Mailing Address - Fax:
Practice Address - Street 1:716 CASTLE HEIGHTS CT
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2670
Practice Address - Country:US
Practice Address - Phone:615-444-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000047781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice