Provider Demographics
NPI:1538383187
Name:MORTVEDT, DAVID MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:MORTVEDT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15100 WASHINGTON ST
Mailing Address - Street 2:202
Mailing Address - City:HAYMARKET
Mailing Address - State:VA
Mailing Address - Zip Code:20169
Mailing Address - Country:US
Mailing Address - Phone:703-754-0727
Mailing Address - Fax:703-754-9924
Practice Address - Street 1:15100 WASHINGTON ST
Practice Address - Street 2:202
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169
Practice Address - Country:US
Practice Address - Phone:703-754-0727
Practice Address - Fax:703-754-9924
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010086271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice