Provider Demographics
NPI:1699853887
Name:JOHNSON, KELLEY PURVIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:PURVIS
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 1:18121 LAGOS WAY
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-2764
Mailing Address - Country:US
Mailing Address - Phone:239-597-2437
Mailing Address - Fax:
Practice Address - Street 1:1454 MADISON AVE W
Practice Address - Street 2:
Practice Address - City:IMMOKALEE
Practice Address - State:FL
Practice Address - Zip Code:34142-2200
Practice Address - Country:US
Practice Address - Phone:239-658-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15182122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist