Provider Demographics
NPI:1205865904
Name:CHRISTENSEN, GARY WAYNE (DENTIST)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 2ND ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-1830
Mailing Address - Country:US
Mailing Address - Phone:952-474-6515
Mailing Address - Fax:952-474-1206
Practice Address - Street 1:348 2ND ST
Practice Address - Street 2:SUITE 200
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-1830
Practice Address - Country:US
Practice Address - Phone:952-474-6515
Practice Address - Fax:952-474-1206
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice