Healthcare Provider Details

I. General information

NPI: 1134974215
Provider Name (Legal Business Name): BRYANT GREGORY JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 W THOMAS ST
HAMMOND LA
70401-2840
US

IV. Provider business mailing address

1059 SARATOGA ST APT 2
EAST BOSTON MA
02128-2696
US

V. Phone/Fax

Practice location:
  • Phone: 985-602-2716
  • Fax:
Mailing address:
  • Phone: 985-855-8735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7859
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: