Provider Demographics
NPI:1740730704
Name:SAMUEL W. CHRISTENSEN
Entity type:Organization
Organization Name:SAMUEL W. CHRISTENSEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:53776
Authorized Official - Phone:831-722-1432
Mailing Address - Street 1:390 S GREEN VALLEY RD STE 5
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-3077
Mailing Address - Country:US
Mailing Address - Phone:831-722-1432
Mailing Address - Fax:831-722-7861
Practice Address - Street 1:390 S GREEN VALLEY RD STE 5
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3077
Practice Address - Country:US
Practice Address - Phone:831-722-1432
Practice Address - Fax:831-722-7861
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAMUEL W CHRISTENSEN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53776122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty