Provider Demographics
NPI:1245388255
Name:JOHNSON, MARK STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
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 1:93 OAK AVENUE SOUTH
Mailing Address - Street 2:PO BOX 539
Mailing Address - City:ANNANDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55302-0539
Mailing Address - Country:US
Mailing Address - Phone:320-274-2475
Mailing Address - Fax:320-274-3152
Practice Address - Street 1:93 OAK AVENUE
Practice Address - Street 2:3
Practice Address - City:ANNANDALE
Practice Address - State:MN
Practice Address - Zip Code:55302-0539
Practice Address - Country:US
Practice Address - Phone:320-274-2475
Practice Address - Fax:320-274-3152
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9649122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist