Provider Demographics
NPI:1043504384
Name:JOHNSON, DEREK LYLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:LYLE
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 1:175 BRINKBY AVE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-4327
Mailing Address - Country:US
Mailing Address - Phone:775-825-9225
Mailing Address - Fax:
Practice Address - Street 1:175 BRINKBY AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4327
Practice Address - Country:US
Practice Address - Phone:775-825-9225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV60901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice