Provider Demographics
NPI:1164644647
Name:JOHNSON, BRADFORD (DDS)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:
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 1:801 S PAULINA ST
Mailing Address - Street 2:MC 621
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7210
Mailing Address - Country:US
Mailing Address - Phone:312-355-1661
Mailing Address - Fax:312-355-3864
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:MC 621
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:312-355-1661
Practice Address - Fax:312-355-3864
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics