Provider Demographics
NPI:1104266949
Name:MORTENSEN, SEAN RICHARD (DDS)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:RICHARD
Last Name:MORTENSEN
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 1:2025 W US HIGHWAY 50
Mailing Address - Street 2:A100
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1571
Mailing Address - Country:US
Mailing Address - Phone:719-542-2472
Mailing Address - Fax:
Practice Address - Street 1:2025 W US HIGHWAY 50
Practice Address - Street 2:A100
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1571
Practice Address - Country:US
Practice Address - Phone:719-542-2472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO201996122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist