Provider Demographics
NPI:1225577224
Name:SOUTHWAY ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:SOUTHWAY ORTHODONTICS PLLC
Other - Org Name:CHRISTENSEN ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRET
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:208-791-0428
Mailing Address - Street 1:77 SOUTHWAY AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2203
Mailing Address - Country:US
Mailing Address - Phone:208-798-4427
Mailing Address - Fax:208-743-4807
Practice Address - Street 1:77 SOUTHWAY AVE
Practice Address - Street 2:SUITE D
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2203
Practice Address - Country:US
Practice Address - Phone:208-798-4427
Practice Address - Fax:208-743-4807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD 3069 OR332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment