Healthcare Provider Details

I. General information

NPI: 1790526176
Provider Name (Legal Business Name): ERIC KRISTENSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2024
Last Update Date: 07/27/2024
Certification Date: 07/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 VITALITY DR STE 130
HENDERSON NV
89011-4809
US

IV. Provider business mailing address

1001 SHADOW LN
LAS VEGAS NV
89106-4124
US

V. Phone/Fax

Practice location:
  • Phone: 702-359-7401
  • Fax:
Mailing address:
  • Phone: 734-904-3930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8056
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: