Provider Demographics
NPI:1295279925
Name:LAURIS L JOHNSON DMD PLLC
Entity type:Organization
Organization Name:LAURIS L JOHNSON DMD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-810-8271
Mailing Address - Street 1:7848 WINTER GARDEN VINELAND RD
Mailing Address - Street 2:100
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-5934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7848 WINTER GARDEN VINELAND RD
Practice Address - Street 2:100
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-5934
Practice Address - Country:US
Practice Address - Phone:407-810-8271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL168761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty