Provider Demographics
NPI:1851470264
Name:CHRISTENSEN, M. TODD (DMD)
Entity Type:Individual
Prefix:DR
First Name:M. TODD
Middle Name:
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARVIN
Other - Middle Name:TODD
Other - Last Name:CHRISTENSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:67 S HIGLEY RD
Mailing Address - Street 2:103
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1166
Mailing Address - Country:US
Mailing Address - Phone:480-518-5502
Mailing Address - Fax:480-219-9234
Practice Address - Street 1:67 S HIGLEY RD
Practice Address - Street 2:103
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-1166
Practice Address - Country:US
Practice Address - Phone:480-518-5502
Practice Address - Fax:480-219-9234
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ56041223D0004X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ696742Medicare ID - Type UnspecifiedAHCCCS PROVIDER NUMBER