MEDICARE: DR. LUCIEN SAMUEL JOHNSON III D.M.D.

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	DN0013457	FL

General Provider Information

NPI Number	:	1356461081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUCIEN SAMUEL JOHNSON III D.M.D.

Provider Business Mailing Address
First Line	:	1951 S ALAFAYA TRL
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-8732
Country	:	US
Telephone Number	:	407-282-0002
Fax Number	:	407-282-1602

Provider Business Practice Location Address
First Line	:	1951 S ALAFAYA TRL
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-8732
Country	:	US
Telephone Number	:	407-282-0002
Fax Number	:	407-282-1602

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	07/08/2007

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