Provider Demographics
NPI:1598747040
Name:JOHNSON, MARK ANTHONY (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
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 1:2229 ROCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-7538
Mailing Address - Country:US
Mailing Address - Phone:865-983-1304
Mailing Address - Fax:
Practice Address - Street 1:1362 N GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:ROCKWOOD
Practice Address - State:TN
Practice Address - Zip Code:37854-4108
Practice Address - Country:US
Practice Address - Phone:865-354-1220
Practice Address - Fax:865-354-0112
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000007193122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist