Provider Demographics
NPI:1902070063
Name:MT LINCOLN PLLC
Entity Type:Organization
Organization Name:MT LINCOLN PLLC
Other - Org Name:DENTAL DEPOT OF YUKON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR. OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:BRYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:POGSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-945-8941
Mailing Address - Street 1:2828 NW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7404
Mailing Address - Country:US
Mailing Address - Phone:405-350-1133
Mailing Address - Fax:405-350-1139
Practice Address - Street 1:701 SHEDECK PARKWAY
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099
Practice Address - Country:US
Practice Address - Phone:405-350-1133
Practice Address - Fax:405-350-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty