Provider Demographics
NPI:1013079839
Name:JOHNSON-GRAY, TAMMA L (DDS)
Entity Type:Individual
Prefix:DR
First Name:TAMMA
Middle Name:L
Last Name:JOHNSON-GRAY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-4774
Mailing Address - Country:US
Mailing Address - Phone:225-953-3576
Mailing Address - Fax:
Practice Address - Street 1:3508 GROOM RD
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-3508
Practice Address - Country:US
Practice Address - Phone:225-774-3934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN81701223G0001X
LA6435122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist