Provider Demographics
NPI:1780759241
Name:JOHNSON, MANDY LYNN (DMD)
Entity type:Individual
Prefix:DR
First Name:MANDY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:LYNN
Other - Last Name:MATTERN JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1139 FOUR LEAF LN
Mailing Address - Street 2:
Mailing Address - City:HOLLIDAYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16648-2514
Mailing Address - Country:US
Mailing Address - Phone:814-937-7529
Mailing Address - Fax:
Practice Address - Street 1:900 WEXLER CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-7456
Practice Address - Country:US
Practice Address - Phone:757-963-7684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0362581223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice