Provider Demographics
NPI:1689858698
Name:DDS DENTAL PC
Entity Type:Organization
Organization Name:DDS DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-256-0500
Mailing Address - Street 1:210 N. MUSTANG ROAD
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064
Mailing Address - Country:US
Mailing Address - Phone:405-256-0500
Mailing Address - Fax:
Practice Address - Street 1:210 N. MUSTANG ROAD
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064
Practice Address - Country:US
Practice Address - Phone:405-256-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty