Provider Demographics
NPI:1669662425
Name:KYLE S CHRISTENSEN, DDS, PC
Entity Type:Organization
Organization Name:KYLE S CHRISTENSEN, DDS, PC
Other - Org Name:WASATCH ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-561-8088
Mailing Address - Street 1:1268 W SOUTH JORDAN PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4652
Mailing Address - Country:US
Mailing Address - Phone:801-561-8088
Mailing Address - Fax:801-562-8286
Practice Address - Street 1:1268 W SOUTH JORDAN PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4652
Practice Address - Country:US
Practice Address - Phone:801-561-8088
Practice Address - Fax:801-562-8286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT550719194003Medicaid
UTU77294Medicare UPIN