Provider Demographics
NPI:1447355052
Name:JOHNSON, MARK C (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
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:PO BOX 396
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:NE
Mailing Address - Zip Code:68649-0396
Mailing Address - Country:US
Mailing Address - Phone:402-652-3670
Mailing Address - Fax:
Practice Address - Street 1:740 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:NE
Practice Address - Zip Code:68649-5003
Practice Address - Country:US
Practice Address - Phone:402-652-3670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2015-03-03
Deactivation Date:2014-12-04
Deactivation Code:
Reactivation Date:2015-03-03
Provider Licenses
StateLicense IDTaxonomies
NE4322122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist