Provider Demographics
NPI:1740384981
Name:JOHNSON, BRYAN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11525 HIGHLAND RD
Mailing Address - Street 2:SUITE 23
Mailing Address - City:HARTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48353-2726
Mailing Address - Country:US
Mailing Address - Phone:810-632-0303
Mailing Address - Fax:810-632-7305
Practice Address - Street 1:4250 PONTIAC LAKE RD
Practice Address - Street 2:SUITE B
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-1281
Practice Address - Country:US
Practice Address - Phone:248-674-0303
Practice Address - Fax:248-674-2947
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBJ0176151223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI190F37120OtherBCBS OF MI
MIU97197Medicare UPIN
MI190F37120OtherBCBS OF MI
MIOF37120Medicare ID - Type Unspecified