Provider Demographics
NPI:1619168507
Name:EDWARD A. CHRISTENSEN, D.D.S, P.C.
Entity Type:Organization
Organization Name:EDWARD A. CHRISTENSEN, D.D.S, P.C.
Other - Org Name:FOOTHILLS PEDIATRIC DENTISTRY, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-604-9500
Mailing Address - Street 1:916 S. MAIN STREET
Mailing Address - Street 2:#302
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501
Mailing Address - Country:US
Mailing Address - Phone:303-702-9501
Mailing Address - Fax:303-532-2275
Practice Address - Street 1:916 S MAIN ST UNIT 302
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6672
Practice Address - Country:US
Practice Address - Phone:303-702-9501
Practice Address - Fax:303-532-2275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06439063Medicaid