=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861474553
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WAYNE JOHNSTON D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34 WOODLAND AVE
-----------------------------------------------------
City | GARDNER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01440-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-632-6651
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34 WOODLAND AVE
-----------------------------------------------------
City | GARDNER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01440-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-632-6651
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 12012
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------