Provider Demographics
NPI:1750831087
Name:JOHNSON, ROSE MARY (DDS)
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:MARY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4122 SEABREEZE DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250
Mailing Address - Country:US
Mailing Address - Phone:720-467-9222
Mailing Address - Fax:
Practice Address - Street 1:7740 POINT MEADOWS DR STE 4
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9180
Practice Address - Country:US
Practice Address - Phone:720-467-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21954122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist