Healthcare Provider Details

I. General information

NPI: 1689858698
Provider Name (Legal Business Name): DDS DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N. MUSTANG ROAD
MUSTANG OK
73064
US

IV. Provider business mailing address

210 N. MUSTANG ROAD
MUSTANG OK
73064
US

V. Phone/Fax

Practice location:
  • Phone: 405-256-0500
  • Fax:
Mailing address:
  • Phone: 405-256-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SIDNEY LEE JOHNSON
Title or Position: DENTIST
Credential: D.D.S
Phone: 405-256-0500