Provider Demographics
NPI:1497758486
Name:MATHIESEN, CHRISTIAN EDWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:EDWARD
Last Name:MATHIESEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 WEST AVENUE
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-5902
Mailing Address - Country:US
Mailing Address - Phone:518-587-8442
Mailing Address - Fax:518-587-8472
Practice Address - Street 1:154 WEST AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-5902
Practice Address - Country:US
Practice Address - Phone:518-587-8442
Practice Address - Fax:518-587-8472
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0329381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1497758486Medicaid