Provider Demographics
NPI:1891859112
Name:JOHNSON, BRYAN D (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:516 MAIN ST.
Mailing Address - City:MADISON LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56063-0458
Mailing Address - Country:US
Mailing Address - Phone:507-243-3747
Mailing Address - Fax:507-243-3866
Practice Address - Street 1:1025 MARSH ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4752
Practice Address - Country:US
Practice Address - Phone:507-625-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9815122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist