Healthcare Provider Details

I. General information

NPI: 1295901775
Provider Name (Legal Business Name): VERNARD JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 PLEASANT HILL RD #200
DULUTH GA
30096-5899
US

IV. Provider business mailing address

2502 N ROCKY POINT DR SUITE- 1000
TAMPA FL
33607-1421
US

V. Phone/Fax

Practice location:
  • Phone: 770-381-7878
  • Fax:
Mailing address:
  • Phone: 813-288-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN13678
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: