Provider Demographics
NPI:1568560712
Name:CHRISTENSEN, SHAUN (DMD)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:CHRISTENSEN
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 1:155 S MIDLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2601
Mailing Address - Country:US
Mailing Address - Phone:208-466-7424
Mailing Address - Fax:208-466-7512
Practice Address - Street 1:155 S MIDLAND BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2601
Practice Address - Country:US
Practice Address - Phone:208-466-7424
Practice Address - Fax:208-466-7512
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD 3588122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806452800Medicaid