Provider Demographics
NPI:1760815302
Name:ELLIOTT, MARK STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:ELLIOTT
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 1:4205 E HIGHWAY 66
Mailing Address - Street 2:PO BOX 1000
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-9701
Mailing Address - Country:US
Mailing Address - Phone:405-319-7541
Mailing Address - Fax:405-319-7675
Practice Address - Street 1:4205 E HIGHWAY 66
Practice Address - Street 2:DENTAL CLINIC
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-9701
Practice Address - Country:US
Practice Address - Phone:405-319-7541
Practice Address - Fax:405-319-7675
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4511122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist