Provider Demographics
NPI:1811228307
Name:MORTENSON, MARK (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
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: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:502-254-8501
Mailing Address - Fax:502-805-1957
Practice Address - Street 1:1746 HIGHWAY 44 E
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-6131
Practice Address - Country:US
Practice Address - Phone:502-543-2278
Practice Address - Fax:502-531-9303
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY88341223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100139450Medicaid