Healthcare Provider Details

I. General information

NPI: 1013079839
Provider Name (Legal Business Name): TAMMA L JOHNSON-GRAY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3508 GROOM RD
BAKER LA
70714-3508
US

IV. Provider business mailing address

1153 CORNERSTONE DR
BATON ROUGE LA
70810-4774
US

V. Phone/Fax

Practice location:
  • Phone: 225-774-3934
  • Fax:
Mailing address:
  • Phone: 225-953-3576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6435
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8170
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: