Provider Demographics
NPI:1689716839
Name:JOHNSON, GINA B (DMD)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
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:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188
Mailing Address - Country:US
Mailing Address - Phone:678-445-5444
Mailing Address - Fax:678-445-5552
Practice Address - Street 1:2230 TOWNE LAKE PARKWAY
Practice Address - Street 2:BLDG 1300, STE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189
Practice Address - Country:US
Practice Address - Phone:678-445-5444
Practice Address - Fax:678-445-5552
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0117621223D0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9210146OtherDORAL DENTAL
GA102101OtherAVESIS
GA9980277608BMedicaid