Healthcare Provider Details

I. General information

NPI: 1881813756
Provider Name (Legal Business Name): MATTHEW S JOHNSON DDS MSD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14859 N DALE MABRY HWY
TAMPA FL
33618-2027
US

IV. Provider business mailing address

14859 N DALE MABRY HWY
TAMPA FL
33618-2027
US

V. Phone/Fax

Practice location:
  • Phone: 813-964-0828
  • Fax:
Mailing address:
  • Phone: 813-964-0828
  • Fax: 813-964-0928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12335
License Number StateFL

VIII. Authorized Official

Name: MATTHEW S JOHNSON
Title or Position: ORTHODONTIST
Credential: DDS MSD PA
Phone: 813-964-0828