Provider Demographics
NPI:1598248668
Name:JOHNY, MENA
Entity Type:Individual
Prefix:
First Name:MENA
Middle Name:
Last Name:JOHNY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 MISSION BAY CIR APT P-306
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6685
Mailing Address - Country:US
Mailing Address - Phone:321-537-2810
Mailing Address - Fax:
Practice Address - Street 1:24 PUTNAM PIKE
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-1646
Practice Address - Country:US
Practice Address - Phone:860-779-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT123641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice