Provider Demographics
NPI:1083161665
Name:MORTENSON, BRIAN STEVEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:STEVEN
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6895 S CAPTIVA CV
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3473
Mailing Address - Country:US
Mailing Address - Phone:928-830-2763
Mailing Address - Fax:
Practice Address - Street 1:36014 WRATTEN AVE.
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-286-7401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32124122300000X
UT11672604-99221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist