Provider Demographics
NPI:1134579071
Name:JOHNSON, GARY M JR (DMD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:M
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 1:145 TRADERS WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322
Mailing Address - Country:US
Mailing Address - Phone:912-748-4494
Mailing Address - Fax:912-748-9302
Practice Address - Street 1:145 TRADERS WAY
Practice Address - Street 2:SUITE D
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-6005
Practice Address - Country:US
Practice Address - Phone:912-748-4494
Practice Address - Fax:912-748-9302
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015172122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist