Provider Demographics
NPI:1407893597
Name:JOHNSON, GARY WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WILLIAM
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 1:1322 E MICHIGAN AVE
Mailing Address - Street 2:STE 303
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-2199
Mailing Address - Country:US
Mailing Address - Phone:517-374-7100
Mailing Address - Fax:
Practice Address - Street 1:1322 E MICHIGAN AVE
Practice Address - Street 2:STE 303
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-2199
Practice Address - Country:US
Practice Address - Phone:517-374-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010099951223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics