Healthcare Provider Details

I. General information

NPI: 1649416876
Provider Name (Legal Business Name): JOHNSON AND SOUTHARD ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5010 E 68TH ST SUITE 104
TULSA OK
74136-3323
US

IV. Provider business mailing address

5010 E 68TH ST SUITE 104
TULSA OK
74136-3323
US

V. Phone/Fax

Practice location:
  • Phone: 918-493-3880
  • Fax: 918-492-8564
Mailing address:
  • Phone: 918-493-3880
  • Fax: 918-492-8564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number5119
License Number StateOK

VIII. Authorized Official

Name: DR. LAURIE LYNN SOUTHARD
Title or Position: PRESIDENT/ENDODONTIST
Credential: DDS
Phone: 918-493-3880