Provider Demographics
NPI:1790469229
Name:JOHNSON, BLAKE BRUCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:BRUCE
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 1:3705 N MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:TX
Mailing Address - Zip Code:76574-4997
Mailing Address - Country:US
Mailing Address - Phone:512-595-7439
Mailing Address - Fax:
Practice Address - Street 1:3705 N MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574-4997
Practice Address - Country:US
Practice Address - Phone:512-595-7439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX396511223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice