Provider Demographics
NPI:1891080776
Name:ROSENVALL, CHRISTOPHER GREG (DDS)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:GREG
Last Name:ROSENVALL
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 1:12641 OLD GLENN HWY STE 203
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7040
Mailing Address - Country:US
Mailing Address - Phone:907-622-5437
Mailing Address - Fax:
Practice Address - Street 1:12641 OLD GLENN HWY STE 203
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577
Practice Address - Country:US
Practice Address - Phone:907-622-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-18
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023455122300000X
TX328611223P0221X
AK14841223P0221X
AKDEND14841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1583802Medicaid
TX3767600Medicaid