Provider Demographics
NPI:1023251642
Name:JOHNSON, BRADLEY S (DMD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:S
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 1:1551 E MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-5729
Mailing Address - Country:US
Mailing Address - Phone:423-587-8383
Mailing Address - Fax:423-587-8382
Practice Address - Street 1:1551 E MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-5729
Practice Address - Country:US
Practice Address - Phone:423-587-8383
Practice Address - Fax:423-587-8382
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN89501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN151-3459Medicaid