MEDICARE: DR. EDWINA VIRGINIA JOHNSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4606	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	731231901001	OTHER	OK	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1316049141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWINA VIRGINIA JOHNSON DDS

Provider Business Mailing Address
First Line	:	PO BOX 12505
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73157-2505
Country	:	US
Telephone Number	:	405-823-4244
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 HEMINGWAY DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-2235
Country	:	US
Telephone Number	:	405-557-1245
Fax Number	:	405-840-5410

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	07/08/2007

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