Provider Demographics
NPI:1124394176
Name:JOHNSON, MARC (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 S BROADWAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-4555
Mailing Address - Country:US
Mailing Address - Phone:518-886-8610
Mailing Address - Fax:
Practice Address - Street 1:170 S BROADWAY
Practice Address - Street 2:SUITE 2
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-4555
Practice Address - Country:US
Practice Address - Phone:518-886-8610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041547-1122300000X
NY124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No124Q00000XDental ProvidersDental Hygienist