Provider Demographics
NPI:1689982332
Name:METTRY, MARK ELLIS (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ELLIS
Last Name:METTRY
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 1:839 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-7281
Mailing Address - Country:US
Mailing Address - Phone:405-224-7036
Mailing Address - Fax:
Practice Address - Street 1:839 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-7281
Practice Address - Country:US
Practice Address - Phone:405-224-7036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist