Provider Demographics
NPI:1700242039
Name:JOHNSTONE, AUTUMN LEE (BSDH)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:LEE
Last Name:JOHNSTONE
Suffix:
Gender:F
Credentials:BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-0568
Mailing Address - Country:US
Mailing Address - Phone:503-352-8657
Mailing Address - Fax:503-352-8658
Practice Address - Street 1:44 N 11TH AVE
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:OR
Practice Address - Zip Code:97113-9020
Practice Address - Country:US
Practice Address - Phone:503-359-8505
Practice Address - Fax:503-359-8535
Is Sole Proprietor?:No
Enumeration Date:2015-12-31
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH4130124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist