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General NPI Number Information
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NPI Number | 1881967628
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Entity Type | Organization
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Legal Business Name | JOHNSON IMPLANT DENTISRTY ASSOCIATES
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Dates
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Enumeration Date | 02/09/2012
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Last Update Date | 02/09/2012
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Provider Practice Location Address
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Address Line | 6460 MEDICAL CENTER ST SUITE 300
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City | LAS VEGAS
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State | NV
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Zip | 89148-2406
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Country | US
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Telephone | 702-739-6452
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Fax | 702-739-6654
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Provider Business Mailing Address
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Address Line | 6460 MEDICAL CENTER ST SUITE 300
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City | LAS VEGAS
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State | NV
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Zip | 89148-2406
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Country | US
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Telephone | 702-739-6452
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Fax | 702-739-6654
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Authorized Official
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Title or Position | MAXILLOFACIAL PROSTHODONTIST
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Name | DR. ARISTIDES A TSIKOUDAKIS
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Credential | DMD
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Telephone | 702-739-6452
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 2000203290
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License Number State | NV
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