MEDICARE: OMFS SURGERY CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	S228	NV

General Provider Information

NPI Number	:	1043573553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMFS SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	6950 SMOKE RANCH RD
Second Line	:	SUITE 200
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1300
Country	:	US
Telephone Number	:	702-360-8918
Fax Number	:	702-360-2156

Provider Business Practice Location Address
First Line	:	6950 SMOKE RANCH RD
Second Line	:	SUITE 200
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1300
Country	:	US
Telephone Number	:	702-360-8918
Fax Number	:	702-360-2156

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRENDAN G JOHNSON
Credential	:	DDS
Telephone Number	:	702-360-8918

Provider Enumeration Date	:	06/19/2012
Last Update Date	:	06/19/2012

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