Provider Demographics
NPI:1578083465
Name:CHRISTIANSEN, CHAD (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
Last Name:CHRISTIANSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4131
Mailing Address - Country:US
Mailing Address - Phone:307-638-8071
Mailing Address - Fax:
Practice Address - Street 1:2120 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4131
Practice Address - Country:US
Practice Address - Phone:307-638-8071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE73971223G0001X
WY15411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice