Provider Demographics
NPI:1700249935
Name:MORT, IAN THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:THOMAS
Last Name:MORT
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 1:304A VIVELLE AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37210-4618
Mailing Address - Country:US
Mailing Address - Phone:585-259-6306
Mailing Address - Fax:
Practice Address - Street 1:934 OLDHAM DR STE 100
Practice Address - Street 2:
Practice Address - City:NOLENSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37135-8472
Practice Address - Country:US
Practice Address - Phone:615-819-2571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN104711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program