Provider Demographics
NPI:1083983902
Name:JOHNSON, GRANT D (DDS, MS)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 CENTRAL DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-5884
Mailing Address - Country:US
Mailing Address - Phone:817-283-3777
Mailing Address - Fax:817-283-6929
Practice Address - Street 1:2121 CENTRAL DR
Practice Address - Street 2:SUITE 2
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5884
Practice Address - Country:US
Practice Address - Phone:817-283-3777
Practice Address - Fax:817-283-6929
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX188311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics