MEDICARE: RADIANT SMILES PEDIATRIC DENTISTRY, 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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1437013851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADIANT SMILES PEDIATRIC DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	6519 STADIUM DR
Second Line	:
City	:	ZEPHYRHILLS
State	:	FL
Zip	:	33542-7567
Country	:	US
Telephone Number	:	813-328-3122
Fax Number	:	813-328-3072

Provider Business Practice Location Address
First Line	:	6519 STADIUM DR
Second Line	:
City	:	ZEPHYRHILLS
State	:	FL
Zip	:	33542-7567
Country	:	US
Telephone Number	:	813-328-3122
Fax Number	:	813-328-3072

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JONATHAN CLEOPHAS JOHNSON
Credential	:	D.M.D.
Telephone Number	:	813-328-3122

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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