Provider Demographics
NPI:1861439978
Name:MORTIMER, SCOTT ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALLEN
Last Name:MORTIMER
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 1:4495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1417
Mailing Address - Country:US
Mailing Address - Phone:810-743-5131
Mailing Address - Fax:810-743-1111
Practice Address - Street 1:4495 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1417
Practice Address - Country:US
Practice Address - Phone:810-743-5131
Practice Address - Fax:810-743-1111
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010144451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2917015Medicaid