Provider Demographics
NPI:1992385819
Name:DELINE, BRENDAN JAMES (DMD)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:JAMES
Last Name:DELINE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 DON PASQUAL RD NW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-8841
Mailing Address - Country:US
Mailing Address - Phone:505-224-8740
Mailing Address - Fax:
Practice Address - Street 1:145 DON PASQUAL RD NW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-8841
Practice Address - Country:US
Practice Address - Phone:505-224-8740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
NMDD56361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program