Healthcare Provider Details

I. General information

NPI: 1992385819
Provider Name (Legal Business Name): BRENDAN JAMES DELINE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 DON PASQUAL RD NW
LOS LUNAS NM
87031-8841
US

IV. Provider business mailing address

145 DON PASQUAL RD NW
LOS LUNAS NM
87031-8841
US

V. Phone/Fax

Practice location:
  • Phone: 505-224-8740
  • Fax:
Mailing address:
  • Phone: 505-224-8740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD5636
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: