Provider Demographics
NPI:1902863905
Name:MORTENSEN, ROBERT MANNING
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MANNING
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19633 BIG DIOMEDE CIR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8797
Mailing Address - Country:US
Mailing Address - Phone:907-696-8776
Mailing Address - Fax:
Practice Address - Street 1:2925 DEBARR RD
Practice Address - Street 2:ALASKA VA HEALTH CARE SYSTEM/REGIONAL OFFICE, (160)
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-257-4940
Practice Address - Fax:907-257-4953
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13666122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE5614OtherDENTAL LISENCE
MO13666OtherDENTAL LISENCE
KS5510OtherDENTAL LISENCE