Healthcare Provider Details

I. General information

NPI: 1710033774
Provider Name (Legal Business Name): PATRICK TODD JOHNSON D.M.D., P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 EHRLICH RD SUITE150
TAMPA FL
33624-2075
US

IV. Provider business mailing address

5111 EHRLICH RD SUITE150
TAMPA FL
33624-2075
US

V. Phone/Fax

Practice location:
  • Phone: 813-264-1258
  • Fax: 813-265-2083
Mailing address:
  • Phone: 813-264-1258
  • Fax: 813-265-2083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN13415
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: