Provider Demographics
NPI:1083775423
Name:JOHNSON, GREGORY R (DDS)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4153 COLONEL VANDERHORST CIR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8037
Mailing Address - Country:US
Mailing Address - Phone:843-881-0459
Mailing Address - Fax:
Practice Address - Street 1:1204 TWO ISLAND CT
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7436
Practice Address - Country:US
Practice Address - Phone:843-881-8881
Practice Address - Fax:843-881-7828
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC29981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice