Provider Demographics
NPI:1760689038
Name:CHRISTENSEN, SAMUEL WESLEY
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WESLEY
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7545 SOQUEL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-3848
Mailing Address - Country:US
Mailing Address - Phone:831-688-7878
Mailing Address - Fax:831-688-9549
Practice Address - Street 1:7545 SOQUEL DR
Practice Address - Street 2:SUITE B
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-3848
Practice Address - Country:US
Practice Address - Phone:831-688-7878
Practice Address - Fax:831-688-9549
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA537761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice