Provider Demographics
NPI:1609887835
Name:JOHNSON, GERALD PALMER (DMD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:PALMER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SHADOWMOSS PKWY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-6873
Mailing Address - Country:US
Mailing Address - Phone:843-364-3677
Mailing Address - Fax:
Practice Address - Street 1:415 BROCKMAN MCCLIMON RD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-6608
Practice Address - Country:US
Practice Address - Phone:864-898-1432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ32202Medicaid