Provider Demographics
NPI:1841446440
Name:CHRISTENSEN, EUGENE W (DMD)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:W
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:PO BOX 768
Mailing Address - Street 2:
Mailing Address - City:ANTONITO
Mailing Address - State:CO
Mailing Address - Zip Code:81120-0768
Mailing Address - Country:US
Mailing Address - Phone:719-376-2295
Mailing Address - Fax:
Practice Address - Street 1:985 DAHLIA & WEST 10TH AVE.
Practice Address - Street 2:
Practice Address - City:ANTONITO
Practice Address - State:CO
Practice Address - Zip Code:81120
Practice Address - Country:US
Practice Address - Phone:719-376-2295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHD1040051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02040053Medicaid