Healthcare Provider Details

I. General information

NPI: 1629121496
Provider Name (Legal Business Name): MARK W JOHNSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

487 N MAIN SUITE B
THAYNE WY
83127
US

IV. Provider business mailing address

PO BOX 1365
THAYNE WY
83127-1365
US

V. Phone/Fax

Practice location:
  • Phone: 307-883-4222
  • Fax: 307-883-4223
Mailing address:
  • Phone: 307-883-4222
  • Fax: 307-883-4223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1130
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: