Provider Demographics
NPI:1134885684
Name:WAYNE MORTENSEN DMD PC
Entity type:Organization
Organization Name:WAYNE MORTENSEN DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-853-3300
Mailing Address - Street 1:9213 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1737
Mailing Address - Country:US
Mailing Address - Phone:208-853-3300
Mailing Address - Fax:208-258-3282
Practice Address - Street 1:9213 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-1737
Practice Address - Country:US
Practice Address - Phone:208-853-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-09
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental