Provider Demographics
NPI:1306374277
Name:BOTHUN, CHRISTOPHER PAUL (DDS)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:PAUL
Last Name:BOTHUN
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 1:4000 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3905
Mailing Address - Country:US
Mailing Address - Phone:701-775-0641
Mailing Address - Fax:
Practice Address - Street 1:4000 17TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3905
Practice Address - Country:US
Practice Address - Phone:701-775-0641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2312122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist