Basic Information
| Provider Information | |||||||||
| NPI: | 1811903883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | PARKER | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 158 | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975280012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419556053 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1215 NE 7TH ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414796393 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D8582 | OR | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | D8582 | 01 | OR | LICENSE | OTHER |