Provider Demographics
NPI:1336983949
Name:JOHNSON, BRETT DANIEL (DMD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:DANIEL
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 1:3145 GARDEN AVE STE 1278
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7719
Mailing Address - Country:US
Mailing Address - Phone:210-808-3735
Mailing Address - Fax:
Practice Address - Street 1:3145 GARDEN AVE STE 1278
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-7719
Practice Address - Country:US
Practice Address - Phone:210-808-3735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14020331122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist