Provider Demographics
NPI:1538779012
Name:MORTENSEN, TONYA RAE (RDH)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:RAE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 COURTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22551-6390
Mailing Address - Country:US
Mailing Address - Phone:540-895-7330
Mailing Address - Fax:
Practice Address - Street 1:5205 COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:SPOTSYLVANIA
Practice Address - State:VA
Practice Address - Zip Code:22551-6390
Practice Address - Country:US
Practice Address - Phone:540-865-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-09
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402207909124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist