Provider Demographics
NPI:1790826360
Name:MARK R JOHNSON,DDS,PA
Entity Type:Organization
Organization Name:MARK R JOHNSON,DDS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-666-2444
Mailing Address - Street 1:335 OLD TAPPAN RD
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-6805
Mailing Address - Country:US
Mailing Address - Phone:201-666-2444
Mailing Address - Fax:201-666-2444
Practice Address - Street 1:335 OLD TAPPAN RD
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675-6805
Practice Address - Country:US
Practice Address - Phone:201-666-2444
Practice Address - Fax:201-666-2444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ79371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty