Provider Demographics
NPI:1437450897
Name:JOHNSTON, MARY SMOAK (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:SMOAK
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:201 W 8TH ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3038
Mailing Address - Country:US
Mailing Address - Phone:719-562-4447
Mailing Address - Fax:719-583-1801
Practice Address - Street 1:225 S PLEASANTBURG DR
Practice Address - Street 2:SUITE E10
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2544
Practice Address - Country:US
Practice Address - Phone:864-233-7737
Practice Address - Fax:864-233-6559
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX2365Medicaid