Provider Demographics
NPI:1215986617
Name:MASSARO, MARK EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:MASSARO
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 1:3150 E 41ST STREET
Mailing Address - Street 2:STE 141
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-3756
Mailing Address - Country:US
Mailing Address - Phone:918-743-9924
Mailing Address - Fax:918-743-1160
Practice Address - Street 1:3150 E 41ST STREET
Practice Address - Street 2:STE 141
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-3756
Practice Address - Country:US
Practice Address - Phone:918-743-9924
Practice Address - Fax:918-743-1160
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4838122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist