Provider Demographics
NPI:1861985574
Name:JOHNSON, BRENT DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 WESTRIDGE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3048
Mailing Address - Country:US
Mailing Address - Phone:678-583-0330
Mailing Address - Fax:678-583-0660
Practice Address - Street 1:70 WESTRIDGE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3048
Practice Address - Country:US
Practice Address - Phone:678-583-0330
Practice Address - Fax:678-583-0660
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2019-07-23
Deactivation Date:2019-06-16
Deactivation Code:
Reactivation Date:2019-07-19
Provider Licenses
StateLicense IDTaxonomies
GADN015686122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist