Provider Demographics
NPI:1902888340
Name:BRUM, MARK DYAR (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DYAR
Last Name:BRUM
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 1:2001 N CENTRO FAMILIAR SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105
Mailing Address - Country:US
Mailing Address - Phone:505-873-7423
Mailing Address - Fax:
Practice Address - Street 1:2001 N CENTRO FAMILIAR SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105
Practice Address - Country:US
Practice Address - Phone:505-873-7423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist