Provider Demographics
NPI:1245801349
Name:JOHNSON, RYAN (DMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 SW UMATILLA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-7039
Mailing Address - Country:US
Mailing Address - Phone:888-468-0022
Mailing Address - Fax:
Practice Address - Street 1:97829 SHOPPING CENTER AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9135
Practice Address - Country:US
Practice Address - Phone:541-813-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11467122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist