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General NPI Number Information
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NPI Number | 1407968159
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Entity Type | Organization
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Legal Business Name | MORTENSON FAMILY DENTAL
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 8711 OLD BARDSTOWN RD
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City | LOUISVILLE
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State | KY
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Zip | 40291-4435
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Country | US
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Telephone | 502-231-4633
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Fax | 502-231-4722
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Provider Business Mailing Address
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Address Line | 134 N EVERGREEN RD SUITE 102
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City | MIDDLETOWN
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State | KY
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Zip | 40243-1487
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Country | US
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Telephone | 502-245-7103
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Fax | 502-253-2202
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Authorized Official
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Title or Position | GEN. DENTIST/OWNER
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Name | DR. OWEN WAYNE MORTENSON
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Credential |
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Telephone | 502-245-8627
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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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