Provider Demographics
NPI:1447473285
Name:JOHNS, JACKIE C (DMD)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:C
Last Name:JOHNS
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 1:2100 45TH STREET
Mailing Address - Street 2:- SUITE A-8
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407
Mailing Address - Country:US
Mailing Address - Phone:561-842-5619
Mailing Address - Fax:561-844-4085
Practice Address - Street 1:2100 45TH STREET
Practice Address - Street 2:- SUITE A-8
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407
Practice Address - Country:US
Practice Address - Phone:561-842-5619
Practice Address - Fax:561-844-4085
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN92431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice