Healthcare Provider Details

I. General information

NPI: 1760593602
Provider Name (Legal Business Name): MORTENSON FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11708 MAIN ST
MIDDLETOWN KY
40243-1426
US

IV. Provider business mailing address

11708 MAIN ST
MIDDLETOWN KY
40243-1426
US

V. Phone/Fax

Practice location:
  • Phone: 502-245-8627
  • Fax: 502-245-9395
Mailing address:
  • Phone: 502-245-8627
  • Fax: 502-245-9395

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 WAYNE MORTENSON
Title or Position: OWNER/GENERAL DENTIST
Credential: DMD
Phone: 502-245-8627