Provider Demographics
NPI:1194828269
Name:JOHNSON, BRENT T (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880
Mailing Address - Country:US
Mailing Address - Phone:715-395-9954
Mailing Address - Fax:
Practice Address - Street 1:1507 TOWER AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880
Practice Address - Country:US
Practice Address - Phone:715-394-3683
Practice Address - Fax:715-394-7315
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice