Provider Demographics
NPI:1881034890
Name:JOHNSTON, DANIEL TRAVIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:TRAVIS
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8151 E INDIAN BEND RD
Mailing Address - Street 2:STE. 111
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250-4826
Mailing Address - Country:US
Mailing Address - Phone:480-607-9999
Mailing Address - Fax:
Practice Address - Street 1:101 N INDUSTRIAL RD
Practice Address - Street 2:SUITE A.
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-3441
Practice Address - Country:US
Practice Address - Phone:662-680-3383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3734-141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice