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General NPI Number Information
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NPI Number | 1043573553
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Entity Type | Organization
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Legal Business Name | OMFS SURGERY CENTER, LLC
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Dates
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Enumeration Date | 06/19/2012
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Last Update Date | 06/19/2012
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Provider Practice Location Address
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Address Line | 6950 SMOKE RANCH RD SUITE 200
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City | LAS VEGAS
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State | NV
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Zip | 89128-1300
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Country | US
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Telephone | 702-360-8918
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Fax | 702-360-2156
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Provider Business Mailing Address
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Address Line | 6950 SMOKE RANCH RD SUITE 200
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City | LAS VEGAS
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State | NV
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Zip | 89128-1300
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Country | US
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Telephone | 702-360-8918
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Fax | 702-360-2156
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRENDAN G JOHNSON
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Credential | DDS
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Telephone | 702-360-8918
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | S228
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License Number State | NV
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