Provider Demographics
NPI:1497134480
Name:JOHNSON-LEONG, CHARMAINE
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:
Last Name:JOHNSON-LEONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 E OAKLAND PARK BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1664
Mailing Address - Country:US
Mailing Address - Phone:954-566-7479
Mailing Address - Fax:954-306-6910
Practice Address - Street 1:2717 E OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1664
Practice Address - Country:US
Practice Address - Phone:954-566-7479
Practice Address - Fax:954-306-6910
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN159911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice