Provider Demographics
NPI:1619547379
Name:JOHNSON, KATELYN ANN (DMD)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ANN
Last Name:JOHNSON
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 1:2189 CLEVELAND STREET
Mailing Address - Street 2:SUITE 252
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-8200
Mailing Address - Country:US
Mailing Address - Phone:727-461-9149
Mailing Address - Fax:727-446-8382
Practice Address - Street 1:5215 MANATEE AVENUE WEST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209
Practice Address - Country:US
Practice Address - Phone:941-792-7887
Practice Address - Fax:941-795-6763
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program