1174995518 NPI number — AGOURA FAMILY PRACTICE ASSOCIATES

Table of content: DR. DAVID MAYO CHRISTENSEN DMD, MS (NPI 1013165067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174995518 NPI number — AGOURA FAMILY PRACTICE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGOURA FAMILY PRACTICE ASSOCIATES
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:
Provider Other Organization Name Type Code:
6
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:
1174995518
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2980 N BEVERLY GLEN CIR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90077-1726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-943-4180
Provider Business Mailing Address Fax Number:
888-431-8819

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3180 WILLOW LN
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
THOUSAND OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91361-4941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-494-8520
Provider Business Practice Location Address Fax Number:
888-431-8819
Provider Enumeration Date:
10/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
IQBAL
Authorized Official First Name:
BADER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
805-494-8520

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  G69473 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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