MEDICARE: DR. MARLIN S JOHNSON D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	0013177	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235244906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARLIN S JOHNSON D.M.D.

Provider Business Mailing Address
First Line	:	215 CONSTITUTION DR
Second Line	:
City	:	THOMASVILLE
State	:	GA
Zip	:	31757-4901
Country	:	US
Telephone Number	:	229-226-2386
Fax Number	:	229-226-9838

Provider Business Practice Location Address
First Line	:	215 CONSTITUTION DR
Second Line	:
City	:	THOMASVILLE
State	:	GA
Zip	:	31757-4901
Country	:	US
Telephone Number	:	229-226-2386
Fax Number	:	229-226-9838

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	10/18/2016

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