Provider Demographics
NPI:1679566475
Name:MASON, DEREK DESHAN (DDS)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:DESHAN
Last Name:MASON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:126 ENTERPRISE PATH
Mailing Address - Street 2:SUITE #106
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141
Mailing Address - Country:US
Mailing Address - Phone:770-832-1376
Mailing Address - Fax:770-832-1487
Practice Address - Street 1:126 ENTERPRISE PATH
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2656
Practice Address - Country:US
Practice Address - Phone:770-439-2550
Practice Address - Fax:770-439-2141
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GADN0127101223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry