Provider Demographics
NPI:1083795280
Name:JOHNSON, BRANDON TRAVIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:TRAVIS
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 1:713 ESTES CT
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98363-1452
Mailing Address - Country:US
Mailing Address - Phone:306-452-0489
Mailing Address - Fax:
Practice Address - Street 1:426 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6220
Practice Address - Country:US
Practice Address - Phone:360-457-0489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist