Provider Demographics
NPI:1740306794
Name:JOHNSON, GREGORY P (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:P
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5394 WALNUT AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-2505
Mailing Address - Country:US
Mailing Address - Phone:949-552-5800
Mailing Address - Fax:949-552-8905
Practice Address - Street 1:5394 WALNUT AVE
Practice Address - Street 2:SUITE H
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-2505
Practice Address - Country:US
Practice Address - Phone:949-552-5800
Practice Address - Fax:949-552-8905
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD228131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACGP171091OtherCALIFORNIA CHILDREN'S SERVICES
CA1790054344OtherDENTICAL
CAB22813OtherDENTICAL
CACGP097860OtherCALIFORNIA CHILDREN'S SERVICES