Provider Demographics
NPI:1417150038
Name:ITURRIAGA, CHRISTIAN RENE (DPD)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:RENE
Last Name:ITURRIAGA
Suffix:
Gender:M
Credentials:DPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5219 W CLEARWATER AVE STE 16
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1980
Mailing Address - Country:US
Mailing Address - Phone:509-374-1660
Mailing Address - Fax:509-374-9374
Practice Address - Street 1:5219 W CLEARWATER AVE STE 16
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1980
Practice Address - Country:US
Practice Address - Phone:509-374-1660
Practice Address - Fax:509-374-9374
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-10
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000423122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1091700Medicaid
WA5049226Medicaid