Provider Demographics
NPI:1275971988
Name:JOHNSON, MARK A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
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 1:1714 W HUNT HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5245
Mailing Address - Country:US
Mailing Address - Phone:480-882-3119
Mailing Address - Fax:
Practice Address - Street 1:1714 W HUNT HWY STE 100
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85143-5245
Practice Address - Country:US
Practice Address - Phone:480-882-3119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008712122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist