Provider Demographics
NPI:1689751802
Name:CHRISTENSEN, EDWARD A (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
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 1:1140 W SOUTH BOULDER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2854
Mailing Address - Country:US
Mailing Address - Phone:303-604-9500
Mailing Address - Fax:
Practice Address - Street 1:1120 W SOUTH BOULDER RD
Practice Address - Street 2:SUITE 204
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8951
Practice Address - Country:US
Practice Address - Phone:303-604-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO76661223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02076669Medicaid