Healthcare Provider Details

I. General information

NPI: 1487757761
Provider Name (Legal Business Name): MORTENSON FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N. LOCUST ST
CARLISLE KY
40311
US

IV. Provider business mailing address

134 N EVERGREEN RD SUITE102
MIDDLETOWN KY
40243-1487
US

V. Phone/Fax

Practice location:
  • Phone: 859-289-5418
  • Fax: 859-289-8153
Mailing address:
  • Phone: 502-245-7103
  • Fax: 502-253-2202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. OWEN WAYUNE MORTENSON
Title or Position: GEN. DENTIST/OWNER
Credential: DMD
Phone: 502-245-8627