Provider Demographics
NPI:1124779210
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:
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-301-4267
Mailing Address - Street 1:2345 SOUTHERN BLVD SE STE B1
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-3761
Mailing Address - Country:US
Mailing Address - Phone:505-892-0111
Mailing Address - Fax:
Practice Address - Street 1:2345 SOUTHERN BLVD SE STE B1
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-3761
Practice Address - Country:US
Practice Address - Phone:505-892-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI DENTAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM50284282Medicaid