Healthcare Provider Details

I. General information

NPI: 1730292517
Provider Name (Legal Business Name): DOUGLAS L JOHNSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S SUITE 101
ST AUGUSTINE FL
32080-3108
US

IV. Provider business mailing address

PO BOX 7870
SPRINGDALE AR
72766-7870
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-0505
  • Fax: 904-460-0506
Mailing address:
  • Phone: 479-464-5824
  • Fax: 479-725-2395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN15568
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN15568
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License NumberDN15568
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: