=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093805921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARMAINE JOHNSON-LEONG, DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2655 E OAKLAND PARK BLVD SUITE 1
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33306-1662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-566-7479
-----------------------------------------------------
Fax | 954-565-0450
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2655 E OAKLAND PARK BLVD SUITE 1
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33306-1662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-566-7479
-----------------------------------------------------
Fax | 954-565-0450
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. CHARMAINE JOHNSON-LEONG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 954-566-7479
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN15991
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------