Provider Demographics
NPI:1366000697
Name:MASON, DESSIE DEE (OD)
Entity Type:Individual
Prefix:
First Name:DESSIE
Middle Name:DEE
Last Name:MASON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52185 320TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMING PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55917-8913
Mailing Address - Country:US
Mailing Address - Phone:605-280-5114
Mailing Address - Fax:
Practice Address - Street 1:200 14TH ST NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-4699
Practice Address - Country:US
Practice Address - Phone:507-437-3227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-02
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3618152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3618OtherLICENSE TO PRACTICE