MEDICARE: DR. KATIE EILEEN JOHNSTON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2901020548	MI
2	1223G0001X	General Practice Dentistry	019.027567	IL

General Provider Information

NPI Number	:	1841497179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATIE EILEEN JOHNSTON D.D.S.

Provider Business Mailing Address
First Line	:	40793 DELTA DR
Second Line	:
City	:	NORTHVILLE
State	:	MI
Zip	:	48168-3237
Country	:	US
Telephone Number	:	248-513-0610
Fax Number	:

Provider Business Practice Location Address
First Line	:	3968 PINE GROVE AVE
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-4218
Country	:	US
Telephone Number	:	810-984-2208
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2007
Last Update Date	:	03/27/2012

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