MEDICARE: DR. GARY ROBERT JOHNSON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019017208	IL
2	1223G0001X	General Practice Dentistry	319006856	IL

General Provider Information

NPI Number	:	1649294927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY ROBERT JOHNSON D.D.S.

Provider Business Mailing Address
First Line	:	5646 SAINT CHARLES RD
Second Line	:	SUITE C
City	:	BERKELEY
State	:	IL
Zip	:	60163-1148
Country	:	US
Telephone Number	:	708-544-7474
Fax Number	:

Provider Business Practice Location Address
First Line	:	5646 SAINT CHARLES RD
Second Line	:	SUITE C
City	:	BERKELEY
State	:	IL
Zip	:	60163-1148
Country	:	US
Telephone Number	:	708-544-7474
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	10/26/2015

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