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General NPI Number Information
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NPI Number | 1245390988
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Entity Type | Individual
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Provider Name | MARK C JOHNSEN DDS
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Gender | Male
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Dates
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Enumeration Date | 12/11/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 6982 BOULDER AVENUE
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City | HIGHLAND
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State | CA
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Zip | 92346
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Country | US
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Telephone | 909-862-2121
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Fax | 909-862-6648
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Provider Business Mailing Address
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Address Line | 15707 ROCKFIELD BLVD SUITE 265
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City | IRVINE
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State | CA
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Zip | 92618
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Country | US
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Telephone | 949-600-7046
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Fax | 949-215-6106
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 40622
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License Number State | CA
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