Provider Demographics
NPI:1801094743
Name:MORTENSEN, ANDREW GEORGE (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:GEORGE
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:18837 BROOKHURST ST
Mailing Address - Street 2:SUITE # 109
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7301
Mailing Address - Country:US
Mailing Address - Phone:714-964-4183
Mailing Address - Fax:714-964-7023
Practice Address - Street 1:18837 BROOKHURST ST
Practice Address - Street 2:SUITE # 109
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7301
Practice Address - Country:US
Practice Address - Phone:714-964-4183
Practice Address - Fax:714-964-7023
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28769122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist