Healthcare Provider Details

I. General information

NPI: 1598747040
Provider Name (Legal Business Name): MARK ANTHONY JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1362 N GATEWAY AVE
ROCKWOOD TN
37854-4108
US

IV. Provider business mailing address

2229 ROCKINGHAM DR
MARYVILLE TN
37803-7538
US

V. Phone/Fax

Practice location:
  • Phone: 865-354-1220
  • Fax: 865-354-0112
Mailing address:
  • Phone: 865-983-1304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS0000007193
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: