Provider Demographics
NPI:1710033774
Name:JOHNSON, PATRICK TODD (DMD, PA)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:TODD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 EHRLICH RD
Mailing Address - Street 2:SUITE150
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-2075
Mailing Address - Country:US
Mailing Address - Phone:813-264-1258
Mailing Address - Fax:813-265-2083
Practice Address - Street 1:5111 EHRLICH RD
Practice Address - Street 2:SUITE150
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-2075
Practice Address - Country:US
Practice Address - Phone:813-264-1258
Practice Address - Fax:813-265-2083
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN134151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN13415OtherSTATE LICENSE NUMBER