Healthcare Provider Details

I. General information

NPI: 1689770679
Provider Name (Legal Business Name): MARC G JOHNSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N MAIN ST
CANANDAIGUA NY
14424-1022
US

IV. Provider business mailing address

500 N MAIN ST
CANANDAIGUA NY
14424-1022
US

V. Phone/Fax

Practice location:
  • Phone: 585-394-3322
  • Fax: 585-394-1175
Mailing address:
  • Phone: 585-394-3322
  • Fax: 585-394-1175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number048311
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: