Provider Demographics
NPI:1497891881
Name:JOHNSON, GREGORY M (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:M
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 1:1063 W PEARCE BLVD
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-1019
Mailing Address - Country:US
Mailing Address - Phone:636-327-6880
Mailing Address - Fax:636-327-6881
Practice Address - Street 1:1063 W PEARCE BLVD
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-1019
Practice Address - Country:US
Practice Address - Phone:636-327-6880
Practice Address - Fax:636-327-6881
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20030121431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice