Provider Demographics
NPI:1285703900
Name:CHRISTENSEN, COREY D (DDS)
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:D
Last Name:CHRISTENSEN
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 1:3805 HIDDEN HAVEN ST
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-7522
Mailing Address - Country:US
Mailing Address - Phone:208-524-4020
Mailing Address - Fax:
Practice Address - Street 1:2205 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8016
Practice Address - Country:US
Practice Address - Phone:208-529-3660
Practice Address - Fax:208-529-3666
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD37031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6I310OtherBLUE CROSS OF IDAHO
ID806625301Medicaid
ID1482771OtherUNITED CONCORDIA