Specialty |
Taxonomy Code | Specialty Code | Provider Type | |
Dental |
261QD0000X |
| NPI # | 1447458070 |
| LBN Legal business name | MORTENSON FAMILY DENTAL CTR-JEFFERSONVILLE |
| Authorized official | OWEN MORTENSON - (OWNER PROVIDER) |
| Entity | Organization |
| Organization subpart 1 | No |
| Enumeration date | 07/05/2007 |
| Last updated | 08/22/2020 - About 6 years ago |
| Identifiers | n/a |
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