Provider Demographics
NPI:1649416876
Name:JOHNSON AND SOUTHARD ENDODONTICS
Entity Type:Organization
Organization Name:JOHNSON AND SOUTHARD ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-493-3880
Mailing Address - Street 1:5010 E 68TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3323
Mailing Address - Country:US
Mailing Address - Phone:918-493-3880
Mailing Address - Fax:918-492-8564
Practice Address - Street 1:5010 E 68TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3323
Practice Address - Country:US
Practice Address - Phone:918-493-3880
Practice Address - Fax:918-492-8564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK51191223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty