Provider Demographics
NPI:1245390988
Name:JOHNSEN, MARK C (DDS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:C
Last Name:JOHNSEN
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 1:15707 ROCKFIELD BLVD
Mailing Address - Street 2:SUITE 265
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618
Mailing Address - Country:US
Mailing Address - Phone:949-600-7046
Mailing Address - Fax:949-215-6106
Practice Address - Street 1:6982 BOULDER AVENUE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346
Practice Address - Country:US
Practice Address - Phone:909-862-2121
Practice Address - Fax:909-862-6648
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40622122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist