Provider Demographics
NPI:1902032063
Name:MARK A. JOHNSON DDS PS
Entity Type:Organization
Organization Name:MARK A. JOHNSON DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-254-1590
Mailing Address - Street 1:601 SE 117TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5297
Mailing Address - Country:US
Mailing Address - Phone:360-254-1590
Mailing Address - Fax:360-254-1939
Practice Address - Street 1:601 SE 117TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5297
Practice Address - Country:US
Practice Address - Phone:360-254-1590
Practice Address - Fax:360-254-1939
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
WA60951223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty