Provider Demographics
NPI:1790706158
Name:CHRISTIE, TODD E (DMD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:E
Last Name:CHRISTIE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1694 W HIBISCUS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2636
Mailing Address - Country:US
Mailing Address - Phone:321-729-0004
Mailing Address - Fax:321-729-0994
Practice Address - Street 1:1694 W HIBISCUS BLVD STE A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2636
Practice Address - Country:US
Practice Address - Phone:321-729-0004
Practice Address - Fax:321-729-0994
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN14545122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist