Provider Demographics
NPI:1548620107
Name:JOHNSTON, TARA MARIA (DDS)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:MARIA
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3710
Mailing Address - Country:US
Mailing Address - Phone:650-727-3480
Mailing Address - Fax:
Practice Address - Street 1:210 SAN MATEO RD STE 104
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-7172
Practice Address - Country:US
Practice Address - Phone:650-726-2144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100418122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist