Provider Demographics
NPI:1790863983
Name:MORTELL, JOHN W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:MORTELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 SPRINGFIELD DR STE 280
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2242
Mailing Address - Country:US
Mailing Address - Phone:630-893-7900
Mailing Address - Fax:630-893-8212
Practice Address - Street 1:290 SPRINGFIELD DR STE 280
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2242
Practice Address - Country:US
Practice Address - Phone:630-893-7900
Practice Address - Fax:630-893-8212
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A164431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice