Provider Demographics
NPI:1285753665
Name:JOHNSON, GREGORY L (DDS)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:L
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 1:16901 ALGONQUIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649
Mailing Address - Country:US
Mailing Address - Phone:714-846-0638
Mailing Address - Fax:714-840-5979
Practice Address - Street 1:16901 ALGONQUIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649
Practice Address - Country:US
Practice Address - Phone:714-846-0638
Practice Address - Fax:714-840-5979
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA446031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice