MEDICARE: JEFFERY MORTENSON DMD

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	7480	KY

General Provider Information

NPI Number	:	1962519355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFERY MORTENSON DMD

Provider Business Mailing Address
First Line	:	11708 MAIN ST
Second Line	:
City	:	MIDDLETOWN
State	:	KY
Zip	:	40243-1426
Country	:	US
Telephone Number	:	502-245-8627
Fax Number	:	502-245-9395

Provider Business Practice Location Address
First Line	:	11708 MAIN ST
Second Line	:
City	:	MIDDLETOWN
State	:	KY
Zip	:	40243-1426
Country	:	US
Telephone Number	:	502-245-8627
Fax Number	:	502-245-9395

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

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	07/08/2007

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