Healthcare Provider Details

I. General information

NPI: 1295402733
Provider Name (Legal Business Name): CHRISTIAN UNDERWOOD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

1451W FARMINGTON AVE
FARMINGTON CT
06032-1039
US

V. Phone/Fax

Practice location:
  • Phone: 970-819-0686
  • Fax:
Mailing address:
  • Phone: 970-819-0686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number084838
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: