MEDICARE: DR. GARY O. JOHNSON DDS

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	122300000X	Dentist	12455	TX

General Provider Information

NPI Number	:	1902867880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY O. JOHNSON DDS

Provider Business Mailing Address
First Line	:	1920 W LOOP ST
Second Line	:
City	:	EL CAMPO
State	:	TX
Zip	:	77437-8007
Country	:	US
Telephone Number	:	979-543-5221
Fax Number	:	979-543-5245

Provider Business Practice Location Address
First Line	:	1920 W LOOP ST
Second Line	:
City	:	EL CAMPO
State	:	TX
Zip	:	77437-8007
Country	:	US
Telephone Number	:	979-543-5221
Fax Number	:	979-543-5245

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

Provider Enumeration Date	:	03/30/2006
Last Update Date	:	07/08/2007

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