Provider Demographics
NPI:1902867880
Name:JOHNSON, GARY O (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:O
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 1:1920 W LOOP ST
Mailing Address - Street 2:
Mailing Address - City:EL CAMPO
Mailing Address - State:TX
Mailing Address - Zip Code:77437-8007
Mailing Address - Country:US
Mailing Address - Phone:979-543-5221
Mailing Address - Fax:979-543-5245
Practice Address - Street 1:1920 W LOOP ST
Practice Address - Street 2:
Practice Address - City:EL CAMPO
Practice Address - State:TX
Practice Address - Zip Code:77437-8007
Practice Address - Country:US
Practice Address - Phone:979-543-5221
Practice Address - Fax:979-543-5245
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12455122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist