Provider Demographics
NPI:1861611535
Name:YOUNGKER, MARK L (DDS, MS, INC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:YOUNGKER
Suffix:
Gender:M
Credentials:DDS, MS, INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD STE 113
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1722
Mailing Address - Country:US
Mailing Address - Phone:405-752-0300
Mailing Address - Fax:405-752-5575
Practice Address - Street 1:4401 W MEMORIAL RD STE 113
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1722
Practice Address - Country:US
Practice Address - Phone:405-752-0300
Practice Address - Fax:405-752-5575
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK545041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1972650497Medicare UPIN
OK1375680803Medicare UPIN