1093805921 NPI number — CHARMAINE JOHNSON-LEONG, DDS, PA

Table of content: (NPI 1093805921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093805921 NPI number — CHARMAINE JOHNSON-LEONG, DDS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARMAINE JOHNSON-LEONG, DDS, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093805921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2655 E OAKLAND PARK BLVD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33306-1662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-566-7479
Provider Business Mailing Address Fax Number:
954-565-0450

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2655 E OAKLAND PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33306-1662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-566-7479
Provider Business Practice Location Address Fax Number:
954-565-0450
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON-LEONG
Authorized Official First Name:
CHARMAINE
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
954-566-7479

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN15991 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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