Provider Demographics
NPI:1962410795
Name:MORTIERE, CAROL FAY
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:FAY
Last Name:MORTIERE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7205 SW DRAKESTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-7467
Mailing Address - Country:US
Mailing Address - Phone:580-531-0281
Mailing Address - Fax:
Practice Address - Street 1:7205 SW DRAKESTONE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-7467
Practice Address - Country:US
Practice Address - Phone:580-531-0281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant