Provider Demographics
NPI:1568671873
Name:JOHNSON, GREGORY WADE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:WADE
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 1:129 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-4101
Mailing Address - Country:US
Mailing Address - Phone:918-279-8880
Mailing Address - Fax:918-279-1698
Practice Address - Street 1:129 S BROADWAY
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-4101
Practice Address - Country:US
Practice Address - Phone:918-279-8880
Practice Address - Fax:918-279-1698
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK36501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice