Provider Demographics
NPI:1972734515
Name:MORTENSON, CELESTE C (DDS)
Entity Type:Individual
Prefix:DR
First Name:CELESTE
Middle Name:C
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 N GATEWAY DR STE 175
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9825
Mailing Address - Country:US
Mailing Address - Phone:435-752-0605
Mailing Address - Fax:435-755-8574
Practice Address - Street 1:169 N GATEWAY DR STE 175
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9825
Practice Address - Country:US
Practice Address - Phone:435-752-0605
Practice Address - Fax:435-755-8574
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7364168-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist