Healthcare Provider Details

I. General information

NPI: 1346210168
Provider Name (Legal Business Name): JEFFREY ROLAND JOHNSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7134 S YALE AVE SUITE 205
TULSA OK
74136-6372
US

IV. Provider business mailing address

7134 S YALE AVE SUITE 205
TULSA OK
74136-6372
US

V. Phone/Fax

Practice location:
  • Phone: 918-523-5080
  • Fax: 918-523-5081
Mailing address:
  • Phone: 918-523-5080
  • Fax: 918-523-5081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3709
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: