Provider Demographics
NPI:1205920071
Name:BEAR, JOHNNY RAY (DDS)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:RAY
Last Name:BEAR
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 1:4905 WICHERS DR
Mailing Address - Street 2:UNIT A
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3028
Mailing Address - Country:US
Mailing Address - Phone:504-340-4888
Mailing Address - Fax:504-340-4829
Practice Address - Street 1:4905 WICHERS DR
Practice Address - Street 2:UNIT A
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3028
Practice Address - Country:US
Practice Address - Phone:504-340-4888
Practice Address - Fax:504-340-4829
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA41621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice