Provider Demographics
NPI:1578911863
Name:MORTENSON, BENNETT DEAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:DEAN
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12810 W ALAMEDA PKWY
Mailing Address - Street 2:UNIT A
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-3116
Mailing Address - Country:US
Mailing Address - Phone:303-987-2273
Mailing Address - Fax:
Practice Address - Street 1:12810 W ALAMEDA PKWY
Practice Address - Street 2:UNIT A
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-3116
Practice Address - Country:US
Practice Address - Phone:303-987-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00202824122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice