Provider Demographics
NPI:1871907725
Name:JOHNSON, GABRIELLE M (DDS)
Entity type:Individual
Prefix:DR
First Name:GABRIELLE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 DORCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6534
Mailing Address - Country:US
Mailing Address - Phone:574-533-2469
Mailing Address - Fax:574-537-1791
Practice Address - Street 1:2046 DORCHESTER CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6534
Practice Address - Country:US
Practice Address - Phone:574-533-2469
Practice Address - Fax:574-537-1791
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2024-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012168A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1871907725Medicaid