Healthcare Provider Details

I. General information

NPI: 1639398597
Provider Name (Legal Business Name): JAY A JOHNSON DDS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 N BRONCO ST STE 102
LAS VEGAS NV
89108-4863
US

IV. Provider business mailing address

3220 N BRONCO ST STE 102
LAS VEGAS NV
89108-4863
US

V. Phone/Fax

Practice location:
  • Phone: 702-396-2223
  • Fax: 702-396-7805
Mailing address:
  • Phone: 702-396-2223
  • Fax: 702-396-7805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2320
License Number StateNV

VIII. Authorized Official

Name: JAY A JOHNSON
Title or Position: OWNER
Credential: DDS
Phone: 70239622223