Provider Demographics
NPI:1578614160
Name:JOHNSON, BRENT CORIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:CORIN
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 1:1216 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38107-1703
Mailing Address - Country:US
Mailing Address - Phone:901-525-3800
Mailing Address - Fax:901-525-4040
Practice Address - Street 1:1216 THOMAS ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38107-1703
Practice Address - Country:US
Practice Address - Phone:901-525-3800
Practice Address - Fax:901-525-4040
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN84711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2002643Medicaid