Provider Demographics
NPI:1245343383
Name:JOHNSON, DONALD TODD (DDS)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:TODD
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 1:3911 EAST 104TH ST. SO.
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137
Mailing Address - Country:US
Mailing Address - Phone:918-299-3955
Mailing Address - Fax:
Practice Address - Street 1:6132 E 61ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-2117
Practice Address - Country:US
Practice Address - Phone:918-494-8634
Practice Address - Fax:918-494-8636
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK50191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU63980Medicare UPIN