Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223D0001X | Dental Public Health | DN011762 | GA |
Y | 1223G0001X | General Practice | DN011762 | GA |
Y | 213EG0000X | General Practice | DN011762 | GA |
NPI | 1689716839 |
---|---|
Provider Name | Dr. Gina B. Johnson |
First Address | Woodstock, GA 30188 |
Second Address | Woodstock, GA 30189 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/02/2007 |
Last Update Date | 30/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
102101 | AVESIS (01) | GA |
9210146 | DORAL DENTAL (01) | GA |
9980277608B | (05) | GA |