Provider Demographics
NPI:1861508715
Name:JOHNSON, GRADY EARL JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:GRADY
Middle Name:EARL
Last Name:JOHNSON
Suffix:JR
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 1:4273 POINT LA VISTA RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-6243
Mailing Address - Country:US
Mailing Address - Phone:904-398-0404
Mailing Address - Fax:904-398-0404
Practice Address - Street 1:4273 POINT LA VISTA RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-6243
Practice Address - Country:US
Practice Address - Phone:904-398-0404
Practice Address - Fax:904-398-0404
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 71371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL074459000Medicaid
AJ7498810OtherDEA