Provider Demographics
NPI:1790708857
Name:JOHNSON, BRENT DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1831 SAINT MICHAELS RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68512-1850
Mailing Address - Country:US
Mailing Address - Phone:402-421-7738
Mailing Address - Fax:
Practice Address - Street 1:3901 PINE LAKE RD STE 250
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5497
Practice Address - Country:US
Practice Address - Phone:402-423-3322
Practice Address - Fax:402-423-3329
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE65661223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry