MEDICARE: MORTENSON FAMILY DENTAL CENTER- FT WRIGHT PLLC

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

General Provider Information

NPI Number	:	1629417183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MORTENSON FAMILY DENTAL CENTER- FT WRIGHT PLLC

Provider Business Mailing Address
First Line	:	1983 DIXIE HWY
Second Line	:
City	:	FT MITCHELL
State	:	KY
Zip	:	41011
Country	:	US
Telephone Number	:	502-955-7102
Fax Number	:

Provider Business Practice Location Address
First Line	:	1983 DIXIE HWY
Second Line	:
City	:	FT MITCHELL
State	:	KY
Zip	:	41011
Country	:	US
Telephone Number	:	502-955-7102
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	KATHIE ARMSTRONG
Credential	:
Telephone Number	:	502-254-8501

Provider Enumeration Date	:	06/18/2013
Last Update Date	:	06/18/2013

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