Provider Demographics
NPI:1760593602
Name:MORTENSON FAMILY DENTAL
Entity Type:Organization
Organization Name:MORTENSON FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MORTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-245-8627
Mailing Address - Street 1:11708 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1426
Mailing Address - Country:US
Mailing Address - Phone:502-245-8627
Mailing Address - Fax:502-245-9395
Practice Address - Street 1:11708 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:KY
Practice Address - Zip Code:40243-1426
Practice Address - Country:US
Practice Address - Phone:502-245-8627
Practice Address - Fax:502-245-9395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental