Provider Demographics
NPI:1255546420
Name:JOHN R CHRISTENSEN DDS MS MS PA
Entity type:Organization
Organization Name:JOHN R CHRISTENSEN DDS MS MS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT, DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS, MS
Authorized Official - Phone:919-489-1543
Mailing Address - Street 1:121 WOODCROFT PARKWAY
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713
Mailing Address - Country:US
Mailing Address - Phone:919-489-1543
Mailing Address - Fax:
Practice Address - Street 1:121 W WOODCROFT PKWY
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-9471
Practice Address - Country:US
Practice Address - Phone:919-489-1543
Practice Address - Fax:919-489-2892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223P0221X, 1223X0400X
NC5274261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8991556Medicaid
NCU39132Medicare UPIN