Provider Demographics
NPI:1285294488
Name:MALLORY, MASON LEBLANC (DDS)
Entity type:Individual
Prefix:DR
First Name:MASON
Middle Name:LEBLANC
Last Name:MALLORY
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 1:2349 HASLETT RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-7758
Mailing Address - Country:US
Mailing Address - Phone:517-420-0300
Mailing Address - Fax:
Practice Address - Street 1:3149 MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:MARLETTE
Practice Address - State:MI
Practice Address - Zip Code:48453-1255
Practice Address - Country:US
Practice Address - Phone:989-635-7541
Practice Address - Fax:989-635-2414
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016001851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice