Provider Demographics
NPI:1669471686
Name:CHRISTENSEN, RUSSELL JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:JOHN
Last Name:CHRISTENSEN
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 1:7315 NE 141ST ST
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-5339
Mailing Address - Country:US
Mailing Address - Phone:425-823-2104
Mailing Address - Fax:425-821-9798
Practice Address - Street 1:7315 NE 141ST ST
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-5339
Practice Address - Country:US
Practice Address - Phone:425-823-2104
Practice Address - Fax:425-821-9798
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
WADE000033621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5044805Medicaid