Healthcare Provider Details

I. General information

NPI: 1013012848
Provider Name (Legal Business Name): CHARLES W MASON SR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 BRUYER WAY
KALISPELL MT
59901-6305
US

IV. Provider business mailing address

34 BRUYER WAY
KALISPELL MT
59901-6305
US

V. Phone/Fax

Practice location:
  • Phone: 406-752-8686
  • Fax: 406-752-9473
Mailing address:
  • Phone: 406-752-8686
  • Fax: 406-752-9473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1941
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: