Provider Demographics
NPI:1083458491
Name:PROCTOR, MASON JAMES (DDS)
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:JAMES
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 SW WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-6307
Mailing Address - Country:US
Mailing Address - Phone:936-585-2778
Mailing Address - Fax:
Practice Address - Street 1:2701 SW WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-6307
Practice Address - Country:US
Practice Address - Phone:817-709-6732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX406511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice