Provider Demographics
NPI:1427797323
Name:CHRISTIANSEN, JOHN CLARK (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CLARK
Last Name:CHRISTIANSEN
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 1:9085 E MINERAL CIR STE 160
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3499
Mailing Address - Country:US
Mailing Address - Phone:303-790-9323
Mailing Address - Fax:303-792-5727
Practice Address - Street 1:2120 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4131
Practice Address - Country:US
Practice Address - Phone:307-638-8071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY16391223G0001X
CO00205130122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO00205130OtherDENTIS
CO00205130OtherDENTIST