Provider Demographics
NPI:1386623965
Name:JOHNSON, MARK P (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:JOHNSON
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 1:315 MCHUGH BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2511
Mailing Address - Country:US
Mailing Address - Phone:910-451-2208
Mailing Address - Fax:
Practice Address - Street 1:315 MCHUGH BLVD
Practice Address - Street 2:2D DENTAL BATTALION/NAVAL DENTAL CENTER
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2511
Practice Address - Country:US
Practice Address - Phone:910-451-8036
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001655-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist