Provider Demographics
NPI:1003137381
Name:MARC G. JOHNSON
Entity Type:Organization
Organization Name:MARC G. JOHNSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-472-6326
Mailing Address - Street 1:150 LYNNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2826
Mailing Address - Country:US
Mailing Address - Phone:585-472-6326
Mailing Address - Fax:585-922-4495
Practice Address - Street 1:150 LYNNWOOD DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2826
Practice Address - Country:US
Practice Address - Phone:585-472-6326
Practice Address - Fax:585-922-4495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0483111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty