Individual
BRENT W MORTENSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
134 EVERGREEN RD, SUITE 103, LOUISVILLE, KY 40243-1487
(502) 410-1702
(502) 244-0817
Mailing address
134 EVERGREEN RD, SUITE 103, LOUISVILLE, KY 40243-1487
(502) 410-1702
(502) 244-0817
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
7229
KY
1223P0221X
Pediatric Dentistry
7229
KY
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
7229
KY
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
7229
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
60072295
—
KY
05
—
64072291
—
KY
Enumeration date
07/18/2006
Last updated
06/18/2014
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