Provider Demographics
NPI:1023041282
Name:MORTENSON, DARRON R (DMD, MS)
Entity Type:Individual
Prefix:
First Name:DARRON
Middle Name:R
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 E HUNT HWY
Mailing Address - Street 2:#29
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5206
Mailing Address - Country:US
Mailing Address - Phone:480-457-1623
Mailing Address - Fax:480-457-1321
Practice Address - Street 1:2510 E HUNT HWY
Practice Address - Street 2:#29
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5206
Practice Address - Country:US
Practice Address - Phone:480-457-1623
Practice Address - Fax:480-457-1321
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ59721223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics