Provider Demographics
NPI:1922235639
Name:CHRISTENSEN, BRAD RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:RICHARD
Last Name:CHRISTENSEN
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 1:5880 CASSIE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4812
Mailing Address - Country:US
Mailing Address - Phone:502-681-7115
Mailing Address - Fax:
Practice Address - Street 1:1149 S 450 W
Practice Address - Street 2:SUITE 105
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-6707
Practice Address - Country:US
Practice Address - Phone:502-681-7115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-20
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY87871223E0200X
UT7999868-99221223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics