Healthcare Provider Details

I. General information

NPI: 1740503564
Provider Name (Legal Business Name): BRANDON JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2010
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 VINE ST SUITE 5
HAYS KS
67601-1949
US

IV. Provider business mailing address

1409 W 44TH ST
HAYS KS
67601-1416
US

V. Phone/Fax

Practice location:
  • Phone: 785-621-2953
  • Fax:
Mailing address:
  • Phone: 913-620-6402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number60616
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: