Provider Demographics
NPI:1043573553
Name:OMFS SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:OMFS SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-360-8918
Mailing Address - Street 1:6950 SMOKE RANCH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1300
Mailing Address - Country:US
Mailing Address - Phone:702-360-8918
Mailing Address - Fax:702-360-2156
Practice Address - Street 1:6950 SMOKE RANCH RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1300
Practice Address - Country:US
Practice Address - Phone:702-360-8918
Practice Address - Fax:702-360-2156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS2281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty