Provider Demographics
NPI:1114105590
Name:MICHAEL MASONBRINK DDS, INC
Entity Type:Organization
Organization Name:MICHAEL MASONBRINK DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MASONBRINK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-866-3507
Mailing Address - Street 1:8373 WAYNESBURG DR SE
Mailing Address - Street 2:
Mailing Address - City:WAYNESBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44688-9538
Mailing Address - Country:US
Mailing Address - Phone:330-866-3507
Mailing Address - Fax:
Practice Address - Street 1:8373 WAYNESBURG DR SE
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:OH
Practice Address - Zip Code:44688-9538
Practice Address - Country:US
Practice Address - Phone:330-866-3507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0222020Medicaid