Provider Demographics
NPI:1699035592
Name:ROULSTON, JOANNA KATHRYN (DDS)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:KATHRYN
Last Name:ROULSTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:KATHRYN
Other - Last Name:AYCOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:5031 S 33RD W AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107
Mailing Address - Country:US
Mailing Address - Phone:918-446-6100
Mailing Address - Fax:918-445-2948
Practice Address - Street 1:5031 S 33RD WEST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-7409
Practice Address - Country:US
Practice Address - Phone:918-446-6100
Practice Address - Fax:918-445-2948
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6380122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist