Provider Demographics
NPI:1497773485
Name:JOHNSON, BRUCE W (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:W
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:PO BOX 270769
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92198-2769
Mailing Address - Country:US
Mailing Address - Phone:858-485-1180
Mailing Address - Fax:858-485-1426
Practice Address - Street 1:15708 POMERADO RD STE N104
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064
Practice Address - Country:US
Practice Address - Phone:858-485-1180
Practice Address - Fax:858-485-1426
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293121223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics