Provider Demographics
NPI:1689296154
Name:FORDTRAN, CHRISTINE WHITAKER
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:WHITAKER
Last Name:FORDTRAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 COVEY TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-3003
Mailing Address - Country:US
Mailing Address - Phone:713-894-6079
Mailing Address - Fax:
Practice Address - Street 1:3507 COVEY TRAIL DR
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-3003
Practice Address - Country:US
Practice Address - Phone:713-894-6079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002025133124Q00000X
TX12789124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODH.002025133OtherREGISTERED DENTAL HYGIENE PRACTITIONER LICENSE
TX12789OtherDENTAL HYGIENE PRACTITIONER LICENSE