Provider Demographics
NPI:1811903883
Name:JOHNSTON, MATTHEW PARKER (DMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PARKER
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 1:1825 NW HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1043
Mailing Address - Country:US
Mailing Address - Phone:414-796-6235
Mailing Address - Fax:
Practice Address - Street 1:1825 NW HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1043
Practice Address - Country:US
Practice Address - Phone:541-479-6623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8582122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD8582OtherLICENSE