MEDICARE: LAURIS L JOHNSON DMD PLLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	16876	FL

General Provider Information

NPI Number	:	1295279925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAURIS L JOHNSON DMD PLLC

Provider Business Mailing Address
First Line	:	7848 WINTER GARDEN VINELAND RD
Second Line	:	100
City	:	WINDERMERE
State	:	FL
Zip	:	34786-5934
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7848 WINTER GARDEN VINELAND RD
Second Line	:	100
City	:	WINDERMERE
State	:	FL
Zip	:	34786-5934
Country	:	US
Telephone Number	:	407-810-8271
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LAURIS JOHNSON
Credential	:	DMD
Telephone Number	:	407-810-8271

Provider Enumeration Date	:	12/15/2016
Last Update Date	:	12/15/2016

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