Provider Demographics
NPI:1164836334
Name:CHRISTIANSON, DREW JAMES (MDT)
Entity Type:Individual
Prefix:MR
First Name:DREW
Middle Name:JAMES
Last Name:CHRISTIANSON
Suffix:
Gender:M
Credentials:MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12936 63RD AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6001
Mailing Address - Country:US
Mailing Address - Phone:763-559-3400
Mailing Address - Fax:
Practice Address - Street 1:12936 63RD AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6001
Practice Address - Country:US
Practice Address - Phone:763-559-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT45125K00000X, 125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist
No125J00000XDental ProvidersDental Therapist