1669662425 NPI number — KYLE S CHRISTENSEN, DDS, PC

Table of content: (NPI 1669662425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669662425 NPI number — KYLE S CHRISTENSEN, DDS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KYLE S CHRISTENSEN, DDS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WASATCH ORAL SURGERY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669662425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1268 W SOUTH JORDAN PKWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SOUTH JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84095-4652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-561-8088
Provider Business Mailing Address Fax Number:
801-562-8286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1268 W SOUTH JORDAN PKWY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SOUTH JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84095-4652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-561-8088
Provider Business Practice Location Address Fax Number:
801-562-8286
Provider Enumeration Date:
07/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHRISTENSEN
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-561-8088

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 204E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 550719194003 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".