Provider Demographics
NPI:1104099118
Name:CHRISTENSEN DENTAL PLLC
Entity type:Organization
Organization Name:CHRISTENSEN DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNDE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-455-1816
Mailing Address - Street 1:4111 CLOCK TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-5006
Mailing Address - Country:US
Mailing Address - Phone:208-455-1816
Mailing Address - Fax:208-459-1446
Practice Address - Street 1:4111 CLOCK TOWER AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-5006
Practice Address - Country:US
Practice Address - Phone:208-455-1816
Practice Address - Fax:208-459-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD37411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6K588OtherBLUE CROSS