Healthcare Provider Details

I. General information

NPI: 1750793261
Provider Name (Legal Business Name): RYAN A JOHNSON DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FAIRVIEW AVE SUITE 6
PONCA CITY OK
74601-1920
US

IV. Provider business mailing address

400 FAIRVIEW AVE SUITE 6
PONCA CITY OK
74601-1920
US

V. Phone/Fax

Practice location:
  • Phone: 580-765-2589
  • Fax: 580-762-2199
Mailing address:
  • Phone: 580-765-2589
  • Fax: 580-762-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6592
License Number StateOK

VIII. Authorized Official

Name: DR. RYAN A JOHNSON
Title or Position: MANAGING PARTNER
Credential: D.D.S.
Phone: 918-260-2395