Provider Demographics
NPI:1952312118
Name:MORTENSON FAMILY DENTAL CENTER - SHELBYVILLE PLLC
Entity Type:Organization
Organization Name:MORTENSON FAMILY DENTAL CENTER - SHELBYVILLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-254-8504
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 1:130 STONECREST RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8126
Practice Address - Country:US
Practice Address - Phone:502-633-1584
Practice Address - Fax:502-633-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental