Provider Demographics
NPI:1770898488
Name:MORTENSON, DAVID GLEN (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GLEN
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 S LINDSAY RD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-1503
Mailing Address - Country:US
Mailing Address - Phone:480-450-0829
Mailing Address - Fax:
Practice Address - Street 1:2208 S BARRINGTON
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-5328
Practice Address - Country:US
Practice Address - Phone:480-450-0829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ80161223E0200X
KY89951223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics