Basic Information
| Provider Information | |||||||||
| NPI: | 1083161665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORTENSON | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6895 S CAPTIVA CV | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD HEIGHTS | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841213473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288302763 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 36014 WRATTEN AVE. | ||||||||
| Address2: | |||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542867401 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2016 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 32124 | TX | N | Dental Providers | Dentist | 1223P0221X | 11672604-9922 | UT | Y | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.