Provider Demographics
NPI:1376655498
Name:MORTENSON FAMILY DENTAL
Entity Type:Organization
Organization Name:MORTENSON FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GEN DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MORTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-245-8627
Mailing Address - Street 1:134 N EVERGREEN RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1487
Mailing Address - Country:US
Mailing Address - Phone:502-245-7103
Mailing Address - Fax:502-253-2202
Practice Address - Street 1:5222 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1704
Practice Address - Country:US
Practice Address - Phone:502-449-7995
Practice Address - Fax:502-449-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental