Provider Demographics
NPI:1376571521
Name:JOHNSON, GREGORY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LEE
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 1:114 MINNIE ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3006
Mailing Address - Country:US
Mailing Address - Phone:907-388-3252
Mailing Address - Fax:
Practice Address - Street 1:114 MINNIE ST
Practice Address - Street 2:SUITE E
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3006
Practice Address - Country:US
Practice Address - Phone:907-388-3252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6571223P0221X
WI29541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0657Medicaid