Provider Demographics
NPI:1154472496
Name:SHIRLEY, MARK D (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:SHIRLEY
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 1:12500 JACINTH CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-5456
Mailing Address - Country:US
Mailing Address - Phone:405-308-6173
Mailing Address - Fax:
Practice Address - Street 1:10001 S PENNSYLVANIA AVE
Practice Address - Street 2:SUITE M240
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6923
Practice Address - Country:US
Practice Address - Phone:405-691-0836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK56131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice