Provider Demographics
NPI:1619184843
Name:JOHNSON, GREGORY MELVIN (DMD)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:MELVIN
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 1:2031 HAWTHORNE STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-8502
Mailing Address - Country:US
Mailing Address - Phone:503-357-5221
Mailing Address - Fax:
Practice Address - Street 1:2031 HAWTHORNE STREET
Practice Address - Street 2:SUITE D
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-8502
Practice Address - Country:US
Practice Address - Phone:503-357-5221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR47371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice