Provider Demographics
NPI:1235244906
Name:JOHNSON, MARLIN S (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARLIN
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31757-4901
Mailing Address - Country:US
Mailing Address - Phone:229-226-2386
Mailing Address - Fax:229-226-9838
Practice Address - Street 1:215 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31757-4901
Practice Address - Country:US
Practice Address - Phone:229-226-2386
Practice Address - Fax:229-226-9838
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00131771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA197090698BMedicaid
GA197090698CMedicaid
GA197090698AMedicaid