Provider Demographics
NPI:1740692938
Name:MORTENSON FAMILY DENTAL CENTER - VERSAILLES, PLLC
Entity type:Organization
Organization Name:MORTENSON FAMILY DENTAL CENTER - VERSAILLES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-254-8504
Mailing Address - Street 1:134 EVERGREEN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1487
Mailing Address - Country:US
Mailing Address - Phone:502-254-8501
Mailing Address - Fax:
Practice Address - Street 1:217 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1266
Practice Address - Country:US
Practice Address - Phone:859-873-0565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental