Provider Demographics
NPI:1578776472
Name:JOHNSTON, MICHAEL S (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 BRUSHY CREEK RD BLDG E
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-0903
Mailing Address - Country:US
Mailing Address - Phone:864-877-2929
Mailing Address - Fax:
Practice Address - Street 1:3115 BRUSHY CREEK RD BLDG E
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-0903
Practice Address - Country:US
Practice Address - Phone:864-877-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3325 & SPEC 5011223X0400X
NC74471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC600881332OtherNC DEPT. OF REVENUE WITHHOLDING NUMBER
SC57-1070771OtherTIN