Provider Demographics
NPI:1629121496
Name:JOHNSON, MARK W (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
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:PO BOX 1365
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127-1365
Mailing Address - Country:US
Mailing Address - Phone:307-883-4222
Mailing Address - Fax:307-883-4223
Practice Address - Street 1:487 N MAIN
Practice Address - Street 2:SUITE B
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127
Practice Address - Country:US
Practice Address - Phone:307-883-4222
Practice Address - Fax:307-883-4223
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY124642900Medicaid