MEDICARE: JOHNSON IMPLANT DENTISRTY ASSOCIATES

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	1223P0700X	Prosthodontics	2000203290	NV

General Provider Information

NPI Number	:	1881967628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNSON IMPLANT DENTISRTY ASSOCIATES

Provider Business Mailing Address
First Line	:	6460 MEDICAL CENTER ST
Second Line	:	SUITE 300
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-2406
Country	:	US
Telephone Number	:	702-739-6452
Fax Number	:	702-739-6654

Provider Business Practice Location Address
First Line	:	6460 MEDICAL CENTER ST
Second Line	:	SUITE 300
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-2406
Country	:	US
Telephone Number	:	702-739-6452
Fax Number	:	702-739-6654

Authorized Official
Title or Position	:	MAXILLOFACIAL PROSTHODONTIST
Name	:	DR. ARISTIDES A TSIKOUDAKIS
Credential	:	DMD
Telephone Number	:	702-739-6452

Provider Enumeration Date	:	02/09/2012
Last Update Date	:	02/09/2012

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