Healthcare Provider Details

I. General information

NPI: 1003137381
Provider Name (Legal Business Name): MARC G. JOHNSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 LYNNWOOD DR
ROCHESTER NY
14618-2826
US

IV. Provider business mailing address

150 LYNNWOOD DR
ROCHESTER NY
14618-2826
US

V. Phone/Fax

Practice location:
  • Phone: 585-472-6326
  • Fax: 585-922-4495
Mailing address:
  • Phone: 585-472-6326
  • Fax: 585-922-4495

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: DR. MARC GREGORY JOHNSON
Title or Position: ORAL SURGEON
Credential: D.D.S.
Phone: 585-472-6326