MEDICARE: LYNN D. MORTENSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5883	OR

General Provider Information

NPI Number	:	1194846121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNN D. MORTENSON DDS

Provider Business Mailing Address
First Line	:	4509 S 6TH ST
Second Line	:	SUITE 302
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97603-4880
Country	:	US
Telephone Number	:	541-883-2630
Fax Number	:	541-883-2630

Provider Business Practice Location Address
First Line	:	4509 S 6TH ST
Second Line	:	SUITE 302
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97603-4880
Country	:	US
Telephone Number	:	541-883-2630
Fax Number	:	541-883-2630

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	07/08/2007

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