Healthcare Provider Details

I. General information

NPI: 1245737832
Provider Name (Legal Business Name): CHELSEA JOHNSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TECHNOLOGY WAY
SCARBOROUGH ME
04074-7654
US

IV. Provider business mailing address

23 BURGET AVE
MEDFORD MA
02155-5422
US

V. Phone/Fax

Practice location:
  • Phone: 207-883-4203
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN4777
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: