Provider Demographics
NPI:1578625091
Name:JOHNSTON, DERRICK THOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:THOR
Last Name:JOHNSTON
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 1:2 NACO RD
Mailing Address - Street 2:P.O. BOX 1898
Mailing Address - City:BISBEE
Mailing Address - State:AZ
Mailing Address - Zip Code:85603
Mailing Address - Country:US
Mailing Address - Phone:520-432-5371
Mailing Address - Fax:520-432-6658
Practice Address - Street 1:2 NACO RD
Practice Address - Street 2:
Practice Address - City:BISBEE
Practice Address - State:AZ
Practice Address - Zip Code:85603
Practice Address - Country:US
Practice Address - Phone:520-432-5371
Practice Address - Fax:520-432-6658
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2689122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist