Healthcare Provider Details

I. General information

NPI: 1124779210
Provider Name (Legal Business Name): TRI DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 SOUTHERN BLVD SE STE B1
RIO RANCHO NM
87124-3761
US

IV. Provider business mailing address

2345 SOUTHERN BLVD SE STE B1
RIO RANCHO NM
87124-3761
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-0111
  • Fax:
Mailing address:
  • Phone: 505-892-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BRENTON MASON
Title or Position: MEMBER
Credential: DMD
Phone: 505-301-4267