Provider Demographics
NPI:1376035196
Name:CELESTE C MORTENSON PC
Entity Type:Organization
Organization Name:CELESTE C MORTENSON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MORTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-512-0133
Mailing Address - Street 1:361 EDGEHILL DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9426
Mailing Address - Country:US
Mailing Address - Phone:435-512-0133
Mailing Address - Fax:435-755-8574
Practice Address - Street 1:169 N GATEWAY DR STE 175
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9825
Practice Address - Country:US
Practice Address - Phone:435-752-0605
Practice Address - Fax:435-755-8574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty