Healthcare Provider Details

I. General information

NPI: 1548620107
Provider Name (Legal Business Name): TARA MARIA JOHNSTON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 SAN MATEO RD STE 104
HALF MOON BAY CA
94019-7172
US

IV. Provider business mailing address

430 N EL CAMINO REAL
SAN MATEO CA
94401-3710
US

V. Phone/Fax

Practice location:
  • Phone: 650-726-2144
  • Fax:
Mailing address:
  • Phone: 650-727-3480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number100418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: