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General NPI Number Information
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NPI Number | 1861290884
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Entity Type | Organization
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Legal Business Name | CORSICANA 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 | 416 N 15TH ST
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City | CORSICANA
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State | TX
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Zip | 75110-4514
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Country | US
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Telephone | 903-872-7388
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Fax | 903-872-6896
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Provider Business Mailing Address
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Address Line | 416 N 15TH ST
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City | CORSICANA
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State | TX
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Zip | 75110-4514
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Country | US
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Telephone | 903-872-7388
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Fax | 903-872-6896
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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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