Provider Demographics
NPI:1629240486
Name:DR MASON DMD INC
Entity Type:Organization
Organization Name:DR MASON DMD INC
Other - Org Name:DR. BRENTON MASON
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:M
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-821-1430
Mailing Address - Street 1:7007 WYOMING BLVD NE
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3987
Mailing Address - Country:US
Mailing Address - Phone:505-821-1430
Mailing Address - Fax:505-821-1442
Practice Address - Street 1:7007 WYOMING BLVD NE
Practice Address - Street 2:SUITE B-2
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3987
Practice Address - Country:US
Practice Address - Phone:505-821-1430
Practice Address - Fax:505-821-1442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2155261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM15740Medicaid