Provider Demographics
NPI:1568585594
Name:CHRISTIANSON, KIRK (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:
Last Name:CHRISTIANSON
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 1:511 SW 10TH AVE STE 1114
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2712
Mailing Address - Country:US
Mailing Address - Phone:503-228-4122
Mailing Address - Fax:503-228-2036
Practice Address - Street 1:511 SW 10TH AVE
Practice Address - Street 2:SUITE 1114
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2712
Practice Address - Country:US
Practice Address - Phone:503-228-4122
Practice Address - Fax:503-228-2036
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD95631223G0001X
ORFC3623053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1568585594OtherNPI
ORFC3623053OtherSTATE LICENSE
WA5050778Medicaid