Healthcare Provider Details

I. General information

NPI: 1891857579
Provider Name (Legal Business Name): MICAH G. MORTENSEN D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6287 S REDWOOD RD STE 202
SALT LAKE CITY UT
84123-6655
US

IV. Provider business mailing address

15359 W COLUMBINE DR
SURPRISE AZ
85379-9190
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-3777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4726746-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: