Provider Demographics
NPI:1275821415
Name:CHRISTENSEN, MICHAEL W (DDS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:CHRISTENSEN
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:PO BOX 830
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020
Mailing Address - Country:US
Mailing Address - Phone:801-495-1610
Mailing Address - Fax:801-210-2059
Practice Address - Street 1:114 E 12450 S
Practice Address - Street 2:SUITE 200
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020
Practice Address - Country:US
Practice Address - Phone:801-495-1610
Practice Address - Fax:801-210-2059
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6317122300000X
UT96897981223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist