Healthcare Provider Details

I. General information

NPI: 1942306741
Provider Name (Legal Business Name): MATHEW ROBERT MOURITSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 BARKLEY CIRCLE
FORT MYERS FL
33907
US

IV. Provider business mailing address

49 BARKLEY CIRCLE
FORT MYERS FL
33907
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-8616
  • Fax: 239-936-1146
Mailing address:
  • Phone: 239-936-8616
  • Fax: 239-936-1146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number265130
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: