Provider Demographics
NPI:1295850576
Name:JOHNS-STOUTAMIRE, LAURIE CARLA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:CARLA
Last Name:JOHNS-STOUTAMIRE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:662 CHERRY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4293
Mailing Address - Country:US
Mailing Address - Phone:904-298-2895
Mailing Address - Fax:904-298-2895
Practice Address - Street 1:2155 LOCH RANE BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5719
Practice Address - Country:US
Practice Address - Phone:904-264-7516
Practice Address - Fax:904-264-8081
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL 134971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice