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General NPI Number Information
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NPI Number | 1134885684
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Entity Type | Organization
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Legal Business Name | WAYNE MORTENSEN DMD PC
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Dates
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Enumeration Date | 11/09/2021
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Last Update Date | 07/06/2023
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Provider Practice Location Address
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Address Line | 9213 W STATE ST
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City | BOISE
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State | ID
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Zip | 83714-1737
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Country | US
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Telephone | 208-853-3300
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Fax |
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Provider Business Mailing Address
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Address Line | 9213 W STATE ST
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City | BOISE
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State | ID
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Zip | 83714-1737
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Country | US
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Telephone | 208-853-3300
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Fax | 208-258-3282
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Authorized Official
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Title or Position | DR/OWNER
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Name | WAYNE MORTENSEN
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Credential | DMD
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Telephone | 208-853-3300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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