Provider Demographics
NPI:1093911406
Name:JOHNSON, DAMON L (DDS)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4420 I40 SERVICE ROAD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73108-1896
Mailing Address - Country:US
Mailing Address - Phone:405-948-8779
Mailing Address - Fax:
Practice Address - Street 1:MYDENTIST 4420 I40 SERVICE ROAD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73108-1896
Practice Address - Country:US
Practice Address - Phone:405-948-8779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK59751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice