MEDICARE: PREMIER SMILE CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN15991	FL

General Provider Information

NPI Number	:	1205215225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER SMILE CENTER

Provider Business Mailing Address
First Line	:	2717 E OAKLAND PARK BLVD
Second Line	:	SUITE 100
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1664
Country	:	US
Telephone Number	:	954-566-7479
Fax Number	:	954-306-6910

Provider Business Practice Location Address
First Line	:	2717 E OAKLAND PARK BLVD
Second Line	:	SUITE 100
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1664
Country	:	US
Telephone Number	:	954-566-7479
Fax Number	:	954-306-6910

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHARMAINE AUBREY JOHNSON-LEONG
Credential	:	D.D.S.
Telephone Number	:	954-566-7479

Provider Enumeration Date	:	05/22/2015
Last Update Date	:	05/22/2015

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