Provider Demographics
NPI:1588768758
Name:MORTENSON FAMILY DENTAL CENTER - PROSPECT PLLC
Entity type:Organization
Organization Name:MORTENSON FAMILY DENTAL CENTER - PROSPECT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ARMSTRONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-254-8501
Mailing Address - Street 1:9219 US HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-8857
Mailing Address - Country:US
Mailing Address - Phone:502-228-2709
Mailing Address - Fax:502-228-9884
Practice Address - Street 1:9219 US HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-8857
Practice Address - Country:US
Practice Address - Phone:502-228-2709
Practice Address - Fax:502-228-9884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1223G0001X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty