Provider Demographics
NPI:1518931260
Name:JOHNSON, BRADLEY E (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:E
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 1:1016 NW NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-1618
Mailing Address - Country:US
Mailing Address - Phone:541-389-1107
Mailing Address - Fax:
Practice Address - Street 1:1016 NW NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-1618
Practice Address - Country:US
Practice Address - Phone:541-389-1107
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice