Provider Demographics
NPI:1508242827
Name:MORTENSON FAMILY DENTAL CENTER - LAWRENCEBURG LLC
Entity Type:Organization
Organization Name:MORTENSON FAMILY DENTAL CENTER - LAWRENCEBURG LLC
Other - Org Name:
Other - Org Type:
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:
Authorized Official - Phone:502-254-8500
Mailing Address - Street 1:1019 WEST EADS PARKWAY US 50
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47102-1842
Mailing Address - Country:US
Mailing Address - Phone:502-254-8500
Mailing Address - Fax:502-805-1957
Practice Address - Street 1:1019 WEST EADS PARKWAY US 50
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47102-1842
Practice Address - Country:US
Practice Address - Phone:502-254-8500
Practice Address - Fax:502-805-1957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental