Provider Demographics
NPI:1225046881
Name:JOHNSON, MARVIN JOHN (DMD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:JOHN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-4418
Mailing Address - Country:US
Mailing Address - Phone:503-472-1468
Mailing Address - Fax:503-434-9214
Practice Address - Street 1:1046 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4418
Practice Address - Country:US
Practice Address - Phone:503-472-1468
Practice Address - Fax:503-434-9214
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD59641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery