Provider Demographics
NPI:1235140781
Name:MADSEN, CHRISTOPHER R
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:R
Last Name:MADSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8012 112TH STREET CT E
Mailing Address - Street 2:SUITE 240
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-7856
Mailing Address - Country:US
Mailing Address - Phone:253-864-0555
Mailing Address - Fax:253-799-9060
Practice Address - Street 1:8012 112TH STREET CT E
Practice Address - Street 2:SUITE 240
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-7856
Practice Address - Country:US
Practice Address - Phone:253-864-0555
Practice Address - Fax:253-799-9060
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000096641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049523Medicaid