Provider Demographics
NPI:1205215225
Name:PREMIER SMILE CENTER
Entity type:Organization
Organization Name:PREMIER SMILE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARMAINE
Authorized Official - Middle Name:AUBREY
Authorized Official - Last Name:JOHNSON-LEONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-566-7479
Mailing Address - Street 1:2717 E OAKLAND PARK BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1664
Mailing Address - Country:US
Mailing Address - Phone:954-566-7479
Mailing Address - Fax:954-306-6910
Practice Address - Street 1:2717 E OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1664
Practice Address - Country:US
Practice Address - Phone:954-566-7479
Practice Address - Fax:954-306-6910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN159911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty