Provider Demographics
NPI:1023769643
Name:WALSTON, JUSTINE E
Entity type:Individual
Prefix:MRS
First Name:JUSTINE
Middle Name:E
Last Name:WALSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1352 NW ST
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023
Mailing Address - Country:US
Mailing Address - Phone:509-756-6999
Mailing Address - Fax:
Practice Address - Street 1:10209 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9782
Practice Address - Country:US
Practice Address - Phone:800-813-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR122616126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant