Provider Demographics
NPI:1366466930
Name:GARY R. JOHNSON, D.D.S., P.C.
Entity Type:Organization
Organization Name:GARY R. JOHNSON, D.D.S., P.C.
Other - Org Name:BERKELEY DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-544-7474
Mailing Address - Street 1:5646 SAINT CHARLES RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BERKELEY
Mailing Address - State:IL
Mailing Address - Zip Code:60163-1148
Mailing Address - Country:US
Mailing Address - Phone:708-544-7474
Mailing Address - Fax:
Practice Address - Street 1:5646 SAINT CHARLES RD
Practice Address - Street 2:SUITE C
Practice Address - City:BERKELEY
Practice Address - State:IL
Practice Address - Zip Code:60163-1148
Practice Address - Country:US
Practice Address - Phone:708-544-7474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental