Provider Demographics
NPI:1841803830
Name:TRI DENTAL, LLC
Entity Type:Organization
Organization Name:TRI DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
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:505-301-4267
Mailing Address - Street 1:3715 LAS ESTANCIAS CT SW STE 101
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-5506
Mailing Address - Country:US
Mailing Address - Phone:505-873-1819
Mailing Address - Fax:
Practice Address - Street 1:3715 LAS ESTANCIAS CT SW STE 101
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-5506
Practice Address - Country:US
Practice Address - Phone:505-873-1819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty