Provider Demographics
NPI:1619072543
Name:JOHNSON, GREGORY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
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 1:8114 KINGSTON ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7764
Mailing Address - Country:US
Mailing Address - Phone:317-272-4755
Mailing Address - Fax:317-272-4756
Practice Address - Street 1:8114 KINGSTON ST
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7764
Practice Address - Country:US
Practice Address - Phone:317-272-4755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120092381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics