Provider Demographics
NPI:1457572372
Name:JOHNSTON, MARK M (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:JOHNSTON
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 1:1850 W MOUNT HOPE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-2482
Mailing Address - Country:US
Mailing Address - Phone:517-482-4623
Mailing Address - Fax:
Practice Address - Street 1:1850 W MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2482
Practice Address - Country:US
Practice Address - Phone:517-482-4623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI140961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice