Healthcare Provider Details

I. General information

NPI: 1831201938
Provider Name (Legal Business Name): MORTENSON FAMILY DENTAL CENTER- CARROLLTON PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2482 HWY 227
CARROLLTON KY
41008-8048
US

IV. Provider business mailing address

PO BOX 437169
LOUISVILLE KY
40253-7169
US

V. Phone/Fax

Practice location:
  • Phone: 502-732-0333
  • Fax: 502-732-0328
Mailing address:
  • Phone: 502-254-8501
  • Fax: 502-805-1957

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: STEPHEN JAMES
Title or Position: CFO
Credential:
Phone: 502-254-8504