Provider Demographics
NPI:1144207838
Name:JOHNSON, JONATHAN CLEOPHAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:CLEOPHAS
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:PO BOX 82245
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-2245
Mailing Address - Country:US
Mailing Address - Phone:251-463-6597
Mailing Address - Fax:
Practice Address - Street 1:801 E BAKER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563
Practice Address - Country:US
Practice Address - Phone:813-349-7600
Practice Address - Fax:813-938-6423
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN181421223P0221X
AL53371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice