Healthcare Provider Details

I. General information

NPI: 1174369912
Provider Name (Legal Business Name): MASON DAVIS ALBERTSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 PARK DR
SAINT ROBERT MO
65584-7860
US

IV. Provider business mailing address

1081 E 18TH ST
ROLLA MO
65401-2448
US

V. Phone/Fax

Practice location:
  • Phone: 573-426-4455
  • Fax: 573-426-6723
Mailing address:
  • Phone: 573-426-4455
  • Fax: 573-426-6723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2024025814
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: