Provider Demographics
NPI:1659157220
Name:PERALTA PERALTA, JOHANNA MARIA (DMD)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:MARIA
Last Name:PERALTA PERALTA
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 1:5018 APEX CIR APT 408
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-2312
Mailing Address - Country:US
Mailing Address - Phone:787-317-4046
Mailing Address - Fax:
Practice Address - Street 1:5170 DAVE ROBBINS WAY
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4348
Practice Address - Country:US
Practice Address - Phone:863-808-4037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL285071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice