Provider Demographics
NPI:1689770679
Name:JOHNSON, MARC G (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:G
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 1:500 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1022
Mailing Address - Country:US
Mailing Address - Phone:585-394-3322
Mailing Address - Fax:585-394-1175
Practice Address - Street 1:500 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1022
Practice Address - Country:US
Practice Address - Phone:585-394-3322
Practice Address - Fax:585-394-1175
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0483111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery