Provider Demographics
NPI:1851453120
Name:JOHNSON, DAVID BRUCE
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:BRUCE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 W KAGY BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5879
Mailing Address - Country:US
Mailing Address - Phone:406-587-2201
Mailing Address - Fax:406-587-0880
Practice Address - Street 1:1125 W KAGY BLVD STE 303
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-5879
Practice Address - Country:US
Practice Address - Phone:406-587-2201
Practice Address - Fax:406-587-0880
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT18641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
091-576OtherUNITED CONCORDIA PROVIDER