Provider Demographics
NPI:1043208267
Name:BRYAN D. JOHNSON, DDS, PA
Entity Type:Organization
Organization Name:BRYAN D. JOHNSON, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-243-3747
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:MADISON LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56063-0458
Mailing Address - Country:US
Mailing Address - Phone:507-243-3747
Mailing Address - Fax:507-243-3866
Practice Address - Street 1:516 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MADISON LAKE
Practice Address - State:MN
Practice Address - Zip Code:56063
Practice Address - Country:US
Practice Address - Phone:507-243-3747
Practice Address - Fax:507-243-3866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND98151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41321JOOtherBLUE CROSS BLUE SHIELD