Healthcare Provider Details

I. General information

NPI: 1245343383
Provider Name (Legal Business Name): DONALD TODD JOHNSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6132 E 61ST ST
TULSA OK
74136-2117
US

IV. Provider business mailing address

3911 EAST 104TH ST. SO.
TULSA OK
74137
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-8634
  • Fax: 918-494-8636
Mailing address:
  • Phone: 918-299-3955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5019
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: