Provider Demographics
NPI:1164049185
Name:CUSTOM DENTAL OF YUKON, PLLC
Entity Type:Organization
Organization Name:CUSTOM DENTAL OF YUKON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-839-9088
Mailing Address - Street 1:4425 GRANT BLVD
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099
Mailing Address - Country:US
Mailing Address - Phone:405-494-4856
Mailing Address - Fax:405-494-4184
Practice Address - Street 1:4425 GRANT BLVD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099
Practice Address - Country:US
Practice Address - Phone:405-494-4856
Practice Address - Fax:405-494-4184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental