Provider Demographics
NPI:1356369169
Name:MORTENSON, BRENT W (DMD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:W
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 EVERGREEN RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1487
Mailing Address - Country:US
Mailing Address - Phone:502-410-1702
Mailing Address - Fax:502-244-0817
Practice Address - Street 1:134 EVERGREEN RD
Practice Address - Street 2:SUITE 103
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1487
Practice Address - Country:US
Practice Address - Phone:502-410-1702
Practice Address - Fax:502-244-0817
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7229122300000X, 1223P0221X, 1223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64072291Medicaid
KY60072295Medicaid
KY64072291Medicaid
KY0047505Medicare PIN
KY0997502Medicare PIN
KYU68878Medicare UPIN
KY0574803Medicare PIN
KY60072295Medicaid