Provider Demographics
NPI:1811047715
Name:JOHNSON, MOSES (DDS)
Entity type:Individual
Prefix:
First Name:MOSES
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 NW MILNER DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3392
Mailing Address - Country:US
Mailing Address - Phone:772-462-3833
Mailing Address - Fax:772-462-3865
Practice Address - Street 1:714 AVENUE C
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4189
Practice Address - Country:US
Practice Address - Phone:772-462-3833
Practice Address - Fax:772-462-3865
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN143171223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN14317OtherMEDICAL LICENSE