Provider Demographics
NPI:1417121732
Name:MORTIMER FAMILY DENTISTRY, PC
Entity Type:Organization
Organization Name:MORTIMER FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MORTIMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-743-5131
Mailing Address - Street 1:4495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1417
Mailing Address - Country:US
Mailing Address - Phone:810-743-5131
Mailing Address - Fax:810-742-1111
Practice Address - Street 1:4495 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1417
Practice Address - Country:US
Practice Address - Phone:810-743-5131
Practice Address - Fax:810-743-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010144451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty