Provider Demographics
NPI:1811923980
Name:JOHNSON, BRENDAN G (DDS)
Entity type:Individual
Prefix:DR
First Name:BRENDAN
Middle Name:G
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 1:6950 SMOKE RANCH RD.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128
Mailing Address - Country:US
Mailing Address - Phone:702-360-8918
Mailing Address - Fax:702-360-2504
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
Practice Address - Country:US
Practice Address - Phone:702-360-8918
Practice Address - Fax:702-360-2504
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3335-S229174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002202009Medicaid
NVU78343Medicare UPIN
NV002202009Medicaid