Provider Demographics
NPI:1831241538
Name:JOHNSON, BRIAN M (DDS SC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 DUNLAP AVE
Mailing Address - Street 2:PO BOX 480
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-1722
Mailing Address - Country:US
Mailing Address - Phone:715-735-5626
Mailing Address - Fax:715-735-3283
Practice Address - Street 1:1838 DUNLAP AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-1722
Practice Address - Country:US
Practice Address - Phone:715-735-5626
Practice Address - Fax:715-735-3283
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1467G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33504900Medicaid