Provider Demographics
NPI:1730292517
Name:JOHNSON, DOUGLAS L (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
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:PO BOX 7870
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72766-7870
Mailing Address - Country:US
Mailing Address - Phone:479-464-5824
Mailing Address - Fax:479-725-2395
Practice Address - Street 1:1301 PLANTATION ISLAND DR S
Practice Address - Street 2:SUITE 101
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-460-0505
Practice Address - Fax:904-460-0506
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN155681223S0112X, 204E00000X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
1615570OtherUNITED CONCORDIA
FL000415568OtherDELTA DENTAL OF FLORIDA
FL84009OtherBCBS INS
FLB15568-1OtherFL HEALTH KIDS
FLP00237430OtherRAILROAD MEDICARE INDIVIDUAL
20-0618977OtherSOUTHCARE MEDICAL PPO
FL84009OtherBCBS INS
FLB15568-1OtherFL HEALTH KIDS