Provider Demographics
NPI:1457759177
Name:ANDREW R. MORTENSEN, D.M.D., P.C.
Entity Type:Organization
Organization Name:ANDREW R. MORTENSEN, D.M.D., P.C.
Other - Org Name:AESTHETIC SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:R
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:970-484-7310
Mailing Address - Street 1:1040 E ELIZABETH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3951
Mailing Address - Country:US
Mailing Address - Phone:970-484-7310
Mailing Address - Fax:970-484-7711
Practice Address - Street 1:1040 E ELIZABETH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3951
Practice Address - Country:US
Practice Address - Phone:970-484-7310
Practice Address - Fax:970-484-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO94001223D0001X
CO74761223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty