Provider Demographics
NPI:1912221052
Name:D. TODD JOHNSON DDS, PC
Entity Type:Organization
Organization Name:D. TODD JOHNSON DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-449-5800
Mailing Address - Street 1:4716 W URBANA ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5997
Mailing Address - Country:US
Mailing Address - Phone:918-449-5800
Mailing Address - Fax:918-455-8958
Practice Address - Street 1:4716 W URBANA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5997
Practice Address - Country:US
Practice Address - Phone:918-449-5800
Practice Address - Fax:918-455-8958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK50191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100091300AMedicaid