Healthcare Provider Details

I. General information

NPI: 1336138031
Provider Name (Legal Business Name): BRENTON MATTHEW MASON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 WYOMING BLVD NE STE B-2
ALBUQUERQUE NM
87109-3987
US

IV. Provider business mailing address

7007 WYOMING BLVD NE STE B-2
ALBUQUERQUE NM
87109-3987
US

V. Phone/Fax

Practice location:
  • Phone: 505-237-0222
  • Fax: 505-821-1442
Mailing address:
  • Phone: 505-237-0222
  • Fax: 505-821-1941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2155
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: