Healthcare Provider Details

I. General information

NPI: 1396003380
Provider Name (Legal Business Name): BRANDON NEELEY CHRISTENSEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 EASTRIDGE CT
GRANITE BAY CA
95746-6429
US

IV. Provider business mailing address

1700 ALTA DR APT 1009
LAS VEGAS NV
89106-4149
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-4500
  • Fax:
Mailing address:
  • Phone: 801-830-8753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number100166
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: