Healthcare Provider Details

I. General information

NPI: 1629240486
Provider Name (Legal Business Name): DR MASON DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 505-821-1430
  • Fax: 505-821-1442
Mailing address:
  • Phone: 505-821-1430
  • Fax: 505-821-1442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDD2155
License Number StateNM

VIII. Authorized Official

Name: DR. BRENTON M MASON
Title or Position: PRESIDENT
Credential: DMD
Phone: 505-821-1430