Provider Demographics
NPI:1578378865
Name:QUITMAN HOMETOWN DENTAL
Entity type:Organization
Organization Name:QUITMAN 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 1:208 S MAIN STREET
Mailing Address - Street 2:PO BOX 1577
Mailing Address - City:QUITMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75783
Mailing Address - Country:US
Mailing Address - Phone:903-763-4441
Mailing Address - Fax:903-763-4131
Practice Address - Street 1:208 S MAIN ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:TX
Practice Address - Zip Code:75783-2548
Practice Address - Country:US
Practice Address - Phone:903-763-4441
Practice Address - Fax:903-763-4131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty