Provider Demographics
NPI:1407281868
Name:MORTENSON FAMILY DENTAL CENTER- CLARKSVILLE
Entity Type:Organization
Organization Name:MORTENSON FAMILY DENTAL CENTER- CLARKSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ARMSTRONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-254-8501
Mailing Address - Street 1:1240 VETERANS PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-2394
Mailing Address - Country:US
Mailing Address - Phone:812-284-2701
Mailing Address - Fax:812-282-2721
Practice Address - Street 1:1240 VETERANS PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-2394
Practice Address - Country:US
Practice Address - Phone:812-284-2701
Practice Address - Fax:812-282-2721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty