MEDICARE: MORTENSON FAMILY DENTAL CENTER - SHELBYVILLE 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1952312118
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MORTENSON FAMILY DENTAL CENTER - SHELBYVILLE PLLC

Provider Business Mailing Address
First Line	:	PO BOX 437169
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40253-7169
Country	:	US
Telephone Number	:	502-254-8501
Fax Number	:	502-805-1957

Provider Business Practice Location Address
First Line	:	130 STONECREST RD
Second Line	:	SUITE 101
City	:	SHELBYVILLE
State	:	KY
Zip	:	40065-8126
Country	:	US
Telephone Number	:	502-633-1584
Fax Number	:	502-633-1509

Authorized Official
Title or Position	:	CFO
Name	:	STEPHEN JAMES
Credential	:
Telephone Number	:	502-254-8504

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	08/18/2014

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