Provider Demographics
NPI:1821228131
Name:JOHNSON, RYAN DANIEL (DMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DANIEL
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 1:2525 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4283
Mailing Address - Country:US
Mailing Address - Phone:217-787-7744
Mailing Address - Fax:217-793-3620
Practice Address - Street 1:2525 W ILES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4283
Practice Address - Country:US
Practice Address - Phone:217-787-7744
Practice Address - Fax:217-793-3620
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist