Healthcare Provider Details

I. General information

NPI: 1144667908
Provider Name (Legal Business Name): BRAD S. JOHNSON, DMD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 K ST
GREENEVILLE TN
37745-6246
US

IV. Provider business mailing address

703 K ST
GREENEVILLE TN
37745-6246
US

V. Phone/Fax

Practice location:
  • Phone: 423-639-6769
  • Fax:
Mailing address:
  • Phone: 423-639-6769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS8950
License Number StateTN

VIII. Authorized Official

Name: MRS. JANICE D HURST
Title or Position: PRACTICE MANAGER
Credential:
Phone: 423-587-8383