Provider Demographics
NPI:1326167396
Name:JOHNSON, BRYAN CARL (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:CARL
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 1:500 COLUMBIA ST STE B
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98674-8491
Mailing Address - Country:US
Mailing Address - Phone:360-225-5600
Mailing Address - Fax:
Practice Address - Street 1:500 COLUMBIA ST STE B
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:WA
Practice Address - Zip Code:98674-8491
Practice Address - Country:US
Practice Address - Phone:360-225-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA87341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice