Healthcare Provider Details

I. General information

NPI: 1710750310
Provider Name (Legal Business Name): CARLY ANAIS JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 PLAZA CT
SAND SPRINGS OK
74063-7915
US

IV. Provider business mailing address

530 PLAZA CT
SAND SPRINGS OK
74063-7915
US

V. Phone/Fax

Practice location:
  • Phone: 918-245-8333
  • Fax:
Mailing address:
  • Phone: 918-245-8333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8243
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: