Provider Demographics
NPI:1629281134
Name:MORTENSEN, DAVID R (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:MORTENSEN
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 1:2013 GREYSTEM CIR
Mailing Address - Street 2:APT #207
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-9336
Mailing Address - Country:US
Mailing Address - Phone:847-244-4455
Mailing Address - Fax:
Practice Address - Street 1:355 GREENLEAF AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PARK CITY
Practice Address - State:IL
Practice Address - Zip Code:60085-5708
Practice Address - Country:US
Practice Address - Phone:847-244-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist