Provider Demographics
NPI:1891789376
Name:CHRISTIANSEN, KEVIN ROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ROY
Last Name:CHRISTIANSEN
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 1:4342 LIBERTY RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6171
Mailing Address - Country:US
Mailing Address - Phone:503-363-6500
Mailing Address - Fax:503-363-6292
Practice Address - Street 1:4342 LIBERTY RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6171
Practice Address - Country:US
Practice Address - Phone:503-363-6500
Practice Address - Fax:503-363-6292
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD58561223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics