Provider Demographics
NPI:1386489532
Name:JOHNSON, JIMMY DYLAN (DMD)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:DYLAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10648 PINE CONE LN
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34945-2247
Mailing Address - Country:US
Mailing Address - Phone:772-359-7639
Mailing Address - Fax:
Practice Address - Street 1:5855 20TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32966-1020
Practice Address - Country:US
Practice Address - Phone:561-396-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN293021223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice