Provider Demographics
NPI:1760929103
Name:MORTENSON FAMILY DENTAL CENTER - MAINEVILLE LLC
Entity Type:Organization
Organization Name:MORTENSON FAMILY DENTAL CENTER - MAINEVILLE LLC
Other - Org Name:KIDS DENTISTREE - MAINEVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:REIBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-254-8500
Mailing Address - Street 1:PO BOX 437169
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40253-7169
Mailing Address - Country:US
Mailing Address - Phone:513-334-4099
Mailing Address - Fax:513-453-7179
Practice Address - Street 1:6028 SOUTH STATE ROAD 48
Practice Address - Street 2:
Practice Address - City:MAINEVILLE
Practice Address - State:OH
Practice Address - Zip Code:45039
Practice Address - Country:US
Practice Address - Phone:513-334-4099
Practice Address - Fax:513-453-7179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty