Provider Demographics
NPI:1457570319
Name:JOHNSON, JAY A (DDS)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:A
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 1:3220 NORTH BRONCO ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-4863
Mailing Address - Country:US
Mailing Address - Phone:702-396-2223
Mailing Address - Fax:702-396-7805
Practice Address - Street 1:3220 NORTH BRONCO ST
Practice Address - Street 2:SUITE 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-4863
Practice Address - Country:US
Practice Address - Phone:702-396-2223
Practice Address - Fax:702-396-7805
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2320122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist