Provider Demographics
NPI:1568568269
Name:CHRISTENSEN, BRET BOYLE (DDS MS)
Entity Type:Individual
Prefix:MR
First Name:BRET
Middle Name:BOYLE
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:77 SOUTHWAY AVE
Mailing Address - Street 2:STE D
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2200
Mailing Address - Country:US
Mailing Address - Phone:208-798-4427
Mailing Address - Fax:208-743-4807
Practice Address - Street 1:77 SOUTHWAY AVE
Practice Address - Street 2:STE D
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2200
Practice Address - Country:US
Practice Address - Phone:208-798-4427
Practice Address - Fax:208-743-4807
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDD3069OR122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010033124OtherREGENCE BLUE SHIELD OF ID