Provider Demographics
NPI:1467623629
Name:MORTENSON FAMILY DENTAL CENTER- CLARKSVILLE, LLC
Entity Type:Organization
Organization Name:MORTENSON FAMILY DENTAL CENTER- CLARKSVILLE, LLC
Other - Org Name:SMILECARE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:502-254-8504
Mailing Address - Street 1:1240 VETERANS PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129
Mailing Address - Country:US
Mailing Address - Phone:812-284-2701
Mailing Address - Fax:812-284-2721
Practice Address - Street 1:1240 VETERANS PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129
Practice Address - Country:US
Practice Address - Phone:812-284-2701
Practice Address - Fax:812-284-2721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010767A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty