Provider Demographics
NPI:1801130703
Name:J. BERT JOHNSON DDS, INC, P.C.
Entity type:Organization
Organization Name:J. BERT JOHNSON DDS, INC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BERT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-744-1255
Mailing Address - Street 1:4715 E 91ST ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-2840
Mailing Address - Country:US
Mailing Address - Phone:918-744-1255
Mailing Address - Fax:918-744-1259
Practice Address - Street 1:4715 E 91ST ST
Practice Address - Street 2:SUITE 110
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-2840
Practice Address - Country:US
Practice Address - Phone:918-744-1255
Practice Address - Fax:918-744-1259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty