Provider Demographics
NPI:1871264234
Name:JOHNSON, DESTYNE FAETH (RDH)
Entity Type:Individual
Prefix:
First Name:DESTYNE
Middle Name:FAETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29540 SW COURTSIDE DR APT 9
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-5436
Mailing Address - Country:US
Mailing Address - Phone:503-507-7083
Mailing Address - Fax:
Practice Address - Street 1:3000 MARKET ST NE STE 228
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1803
Practice Address - Country:US
Practice Address - Phone:800-525-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH8315124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist