Provider Demographics
NPI:1467466516
Name:JOHNSON, GRANVILLE WOODWORTH (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRANVILLE
Middle Name:WOODWORTH
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 1:4118 E PARHAM RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-2742
Mailing Address - Country:US
Mailing Address - Phone:804-266-4499
Mailing Address - Fax:804-261-4801
Practice Address - Street 1:4118 E PARHAM RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-2742
Practice Address - Country:US
Practice Address - Phone:804-266-4499
Practice Address - Fax:804-261-4801
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA50021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice