Provider Demographics
NPI:1003003831
Name:EDWINA V. JOHNSON, D.D.S., P.C.
Entity Type:Organization
Organization Name:EDWINA V. JOHNSON, D.D.S., P.C.
Other - Org Name:DENTAL WORKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MS
Authorized Official - First Name:EDWINA
Authorized Official - Middle Name:VIRGINIA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-557-1245
Mailing Address - Street 1:4200 HEMINGWAY DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-2235
Mailing Address - Country:US
Mailing Address - Phone:405-557-1245
Mailing Address - Fax:
Practice Address - Street 1:4200 HEMINGWAY DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-2235
Practice Address - Country:US
Practice Address - Phone:405-557-1245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKS 46061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1316049141OtherNPI INDIVIDUAL ID
OK731231901001OtherOTHER ID OK
OK731231901001OtherOTHER ID OK