Provider Demographics
NPI:1801022934
Name:MARK D. JOHNSON D.D.S., P.S.
Entity Type:Organization
Organization Name:MARK D. JOHNSON D.D.S., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-565-1695
Mailing Address - Street 1:6927 LAKEWOOD DR W STE C2
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98467-3247
Mailing Address - Country:US
Mailing Address - Phone:253-565-1695
Mailing Address - Fax:253-565-1588
Practice Address - Street 1:6927 LAKEWOOD DR W STE C2
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98467-3247
Practice Address - Country:US
Practice Address - Phone:253-565-1695
Practice Address - Fax:253-565-1588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005841122300000X
WADE60096175122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty