Provider Demographics
NPI:1710098140
Name:MARK E. METTRY DDS, INC.
Entity Type:Organization
Organization Name:MARK E. METTRY DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:METTRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-224-7036
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:405-224-2702
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:405-224-2702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty