Provider Demographics
NPI:1144667908
Name:BRAD S. JOHNSON, DMD, PLLC
Entity type:Organization
Organization Name:BRAD S. JOHNSON, DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-587-8383
Mailing Address - Street 1:703 K ST
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-6246
Mailing Address - Country:US
Mailing Address - Phone:423-639-6769
Mailing Address - Fax:
Practice Address - Street 1:703 K ST
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-6246
Practice Address - Country:US
Practice Address - Phone:423-639-6769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS89501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN151-3459Medicaid