Basic Information
| Provider Information | |||||||||
| NPI: | 1891859112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 458 | ||||||||
| Address2: | 516 MAIN ST. | ||||||||
| City: | MADISON LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560630458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072433747 | ||||||||
| FaxNumber: | 5072433866 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 MARSH ST | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560014752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076254031 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 9815 | MN | Y | Dental Providers | Dentist |
No ID Information.