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General NPI Number Information
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NPI Number | 1023816030
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Entity Type | Organization
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Legal Business Name | RED OAK HOMETOWN DENTAL
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Dates
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Enumeration Date | 03/05/2025
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 101 AUSTIN BLVD STE 100
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City | RED OAK
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State | TX
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Zip | 75154-4661
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Country | US
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Telephone | 972-617-3508
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Fax |
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Provider Business Mailing Address
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Address Line | 101 AUSTIN BLVD STE 100
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City | RED OAK
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State | TX
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Zip | 75154-4661
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Country | US
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Telephone | 972-617-3508
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Fax | 972-576-5202
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Authorized Official
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Title or Position | OWNER
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Name | JORDEN MARK MORTENSEN
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Credential | DMD
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Telephone | 512-520-6365
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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