Healthcare Provider Details

I. General information

NPI: 1811081540
Provider Name (Legal Business Name): MARK A JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SE 120TH AVE SUITE 200
VANCOUVER WA
98683-4090
US

IV. Provider business mailing address

300 SE 120TH AVE SUITE 200
VANCOUVER WA
98683-4090
US

V. Phone/Fax

Practice location:
  • Phone: 360-254-1590
  • Fax: 360-254-1939
Mailing address:
  • Phone: 360-254-1590
  • Fax: 360-254-1939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6095
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: