Provider Demographics
NPI:1841497179
Name:JOHNSTON, KATIE EILEEN (DDS)
Entity type:Individual
Prefix:DR
First Name:KATIE
Middle Name:EILEEN
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KATIE
Other - Middle Name:EILEEN
Other - Last Name:EASTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:40793 DELTA DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-3237
Mailing Address - Country:US
Mailing Address - Phone:248-513-0610
Mailing Address - Fax:
Practice Address - Street 1:3968 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4218
Practice Address - Country:US
Practice Address - Phone:810-984-2208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010205481223G0001X
IL019.0275671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice