Healthcare Provider Details

I. General information

NPI: 1366466930
Provider Name (Legal Business Name): GARY R. JOHNSON, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5646 SAINT CHARLES RD SUITE C
BERKELEY IL
60163-1148
US

IV. Provider business mailing address

5646 SAINT CHARLES RD SUITE C
BERKELEY IL
60163-1148
US

V. Phone/Fax

Practice location:
  • Phone: 708-544-7474
  • Fax:
Mailing address:
  • Phone: 708-544-7474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY ROBERT JOHNSON
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 708-544-7474