Provider Demographics
NPI:1770604696
Name:MASK, DEREK RYAN (DDS)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:RYAN
Last Name:MASK
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 1:2500 MCGEE DR
Mailing Address - Street 2:SUITE 131
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-6722
Mailing Address - Country:US
Mailing Address - Phone:405-321-5143
Mailing Address - Fax:405-321-5350
Practice Address - Street 1:2500 MCGEE DR
Practice Address - Street 2:SUITE 131
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-6722
Practice Address - Country:US
Practice Address - Phone:405-321-5143
Practice Address - Fax:405-321-5350
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK54891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice