Provider Demographics
NPI:1700684701
Name:ENNIS HOMETOWN DENTAL
Entity type:Organization
Organization Name:ENNIS HOMETOWN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDEN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:512-520-6365
Mailing Address - Street 1:400 W ENNIS AVE
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-3904
Mailing Address - Country:US
Mailing Address - Phone:972-875-9031
Mailing Address - Fax:972-878-9031
Practice Address - Street 1:400 W ENNIS AVE
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-3904
Practice Address - Country:US
Practice Address - Phone:972-875-9031
Practice Address - Fax:972-878-9031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty