Basic Information
| Provider Information | |||||||||
| NPI: | 1801178744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTONE | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 KAEN RD STE 367 | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037425300 | ||||||||
| FaxNumber: | 5037425979 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 BEAVERCREEK RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037226313 | ||||||||
| FaxNumber: | 5036558595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2011 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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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 | 124Q00000X | H6133 | OR | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 500684640 | 05 | OR | MEDICAID |