Provider Demographics
NPI:1790092476
Name:MORTENSON, KEVIN M (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
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 1:10127 N BLUE CROSSING WAY
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85743-5219
Mailing Address - Country:US
Mailing Address - Phone:520-505-7761
Mailing Address - Fax:
Practice Address - Street 1:8651 N SILVERBELL RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85743-9515
Practice Address - Country:US
Practice Address - Phone:520-812-7484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD80721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice