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General NPI Number Information
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NPI Number | 1457759177
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Entity Type | Organization
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Legal Business Name | ANDREW R. MORTENSEN, D.M.D., P.C.
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Dates
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Enumeration Date | 12/11/2014
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Last Update Date | 12/11/2014
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Provider Practice Location Address
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Address Line | 1040 E ELIZABETH ST SUITE 201
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City | FORT COLLINS
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State | CO
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Zip | 80524-3951
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Country | US
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Telephone | 970-484-7310
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Fax | 970-484-7711
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Provider Business Mailing Address
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Address Line | 1040 E ELIZABETH ST SUITE 201
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City | FORT COLLINS
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State | CO
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Zip | 80524-3951
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Country | US
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Telephone | 970-484-7310
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Fax | 970-484-7711
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. ANDREW R MORTENSEN
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Credential | D.M.D.
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Telephone | 970-484-7310
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number | 7476
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number | 9400
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License Number State | CO
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