Healthcare Provider Details

I. General information

NPI: 1447355052
Provider Name (Legal Business Name): MARK C JOHNSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date: 12/04/2014
Reactivation Date: 03/03/2015

III. Provider practice location address

740 MAIN ST
NORTH BEND NE
68649-5003
US

IV. Provider business mailing address

PO BOX 396
NORTH BEND NE
68649-0396
US

V. Phone/Fax

Practice location:
  • Phone: 402-652-3670
  • Fax:
Mailing address:
  • Phone: 402-652-3670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4322
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: