Provider Demographics
NPI:1194846121
Name:MORTENSON, LYNN D (DDS)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:D
Last Name:MORTENSON
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 1:4509 S 6TH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4880
Mailing Address - Country:US
Mailing Address - Phone:541-883-2630
Mailing Address - Fax:541-883-2630
Practice Address - Street 1:4509 S 6TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4880
Practice Address - Country:US
Practice Address - Phone:541-883-2630
Practice Address - Fax:541-883-2630
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR58831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice