Provider Demographics
NPI:1154443513
Name:JOHNSON, MARK LESLIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LESLIE
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 1:990 LAMBERT AVE
Mailing Address - Street 2:P.O.BOX 166
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-3015
Mailing Address - Country:US
Mailing Address - Phone:386-334-4968
Mailing Address - Fax:
Practice Address - Street 1:215 S 3RD ST
Practice Address - Street 2:
Practice Address - City:FLAGLER BEACH
Practice Address - State:FL
Practice Address - Zip Code:32136-3613
Practice Address - Country:US
Practice Address - Phone:386-439-9688
Practice Address - Fax:386-439-1915
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN150351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice