Healthcare Provider Details

I. General information

NPI: 1811228307
Provider Name (Legal Business Name): MARK MORTENSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1746 HIGHWAY 44 E
SHEPHERDSVILLE KY
40165-6131
US

IV. Provider business mailing address

PO BOX 437169
LOUISVILLE KY
40253-7169
US

V. Phone/Fax

Practice location:
  • Phone: 502-543-2278
  • Fax: 502-531-9303
Mailing address:
  • Phone: 502-254-8501
  • Fax: 502-805-1957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8834
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8834
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: