Provider Demographics
NPI:1639370778
Name:MAZDA BERENJIAN DDS PA
Entity Type:Organization
Organization Name:MAZDA BERENJIAN DDS PA
Other - Org Name:HENDERSON FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRUMMITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-492-6004
Mailing Address - Street 1:560 DABNEY DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536
Mailing Address - Country:US
Mailing Address - Phone:252-492-6004
Mailing Address - Fax:252-492-0994
Practice Address - Street 1:560 DABNEY DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536
Practice Address - Country:US
Practice Address - Phone:252-492-6004
Practice Address - Fax:252-492-0994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8751122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011G5Medicaid