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General NPI Number Information
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NPI Number | 1205215225
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Entity Type | Organization
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Legal Business Name | PREMIER SMILE CENTER
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Dates
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Enumeration Date | 05/22/2015
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Last Update Date | 05/22/2015
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Provider Practice Location Address
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Address Line | 2717 E OAKLAND PARK BLVD SUITE 100
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City | FORT LAUDERDALE
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State | FL
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Zip | 33306-1664
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Country | US
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Telephone | 954-566-7479
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Fax | 954-306-6910
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Provider Business Mailing Address
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Address Line | 2717 E OAKLAND PARK BLVD SUITE 100
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City | FORT LAUDERDALE
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State | FL
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Zip | 33306-1664
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Country | US
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Telephone | 954-566-7479
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Fax | 954-306-6910
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHARMAINE AUBREY JOHNSON-LEONG
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Credential | D.D.S.
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Telephone | 954-566-7479
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN15991
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License Number State | FL
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