Healthcare Provider Details

I. General information

NPI: 1922235639
Provider Name (Legal Business Name): BRAD RICHARD CHRISTENSEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2009
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 S 450 W SUITE 105
BRIGHAM CITY UT
84302-6707
US

IV. Provider business mailing address

5880 CASSIE DR
SOUTH OGDEN UT
84405-4812
US

V. Phone/Fax

Practice location:
  • Phone: 502-681-7115
  • Fax:
Mailing address:
  • Phone: 502-681-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number8787
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7999868-9922
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: