Provider Demographics
NPI:1659991370
Name:JOHNSON, RYAN DARREN (DMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DARREN
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 1:6704 SUMAC RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-9324
Mailing Address - Country:US
Mailing Address - Phone:505-925-4031
Mailing Address - Fax:505-925-4030
Practice Address - Street 1:6704 SUMAC RIDGE DR
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-9324
Practice Address - Country:US
Practice Address - Phone:505-925-4031
Practice Address - Fax:505-925-4030
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12103826-9923122300000X
NM390200000X
NMTD-00-131390200000X
KY105761223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program