Provider Demographics
NPI:1326214214
Name:DEREK R MASK DDS PLLC
Entity Type:Organization
Organization Name:DEREK R MASK DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-321-5143
Mailing Address - Street 1:2500 MCGEE DR STE 131
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-6796
Mailing Address - Country:US
Mailing Address - Phone:405-321-5143
Mailing Address - Fax:405-321-5350
Practice Address - Street 1:2500 MCGEE DR STE 131
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-6796
Practice Address - Country:US
Practice Address - Phone:405-321-5143
Practice Address - Fax:405-321-5350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK54891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK02809501OtherBLUE CROSS BLUE SHIELD