MEDICARE: MORTENSON FAMILY DENTAL CENTER - WITHAMSVILLE, LLC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1497265318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MORTENSON FAMILY DENTAL CENTER - WITHAMSVILLE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 437169
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40253-7169
Country	:	US
Telephone Number	:	502-254-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	1301 W OHIO PIKE
Second Line	:	STE 5
City	:	AMELIA
State	:	OH
Zip	:	45102
Country	:	US
Telephone Number	:	513-399-5337
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	JEFF REIBEL
Credential	:
Telephone Number	:	502-254-8500

Provider Enumeration Date	:	10/05/2017
Last Update Date	:	02/04/2026

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