Provider Demographics
NPI:1205830882
Name:CHRISTIANSEN, KEITH C (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:C
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 1:261 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BLAIR
Mailing Address - State:NE
Mailing Address - Zip Code:68008-1903
Mailing Address - Country:US
Mailing Address - Phone:402-533-2222
Mailing Address - Fax:402-426-4989
Practice Address - Street 1:261 S 19TH ST
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008-1903
Practice Address - Country:US
Practice Address - Phone:402-533-2222
Practice Address - Fax:402-426-4989
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE47921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470799624-00Medicaid