Provider Demographics
NPI:1417703869
Name:HARRELL, BRETT MASON
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:MASON
Last Name:HARRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2032 RACE ST APT 3R
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1129
Mailing Address - Country:US
Mailing Address - Phone:937-818-5346
Mailing Address - Fax:
Practice Address - Street 1:2050A 2ND ST SE
Practice Address - Street 2:
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-1129
Practice Address - Country:US
Practice Address - Phone:937-818-5346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-26
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14109184-9926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist