Healthcare Provider Details

I. General information

NPI: 1285978288
Provider Name (Legal Business Name): MORTENSON FAMILY DENTAL CENTER - SIMPSONVILLE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 BUCK CREEK RD
SIMPSONVILLE KY
40067-6674
US

IV. Provider business mailing address

PO BOX 437169
LOUISVILLE KY
40253-7169
US

V. Phone/Fax

Practice location:
  • Phone: 502-722-2110
  • Fax: 502-722-2116
Mailing address:
  • Phone: 502-254-8500
  • Fax: 502-245-5021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: RONEL MCCOMBS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 502-254-8500