=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548340433
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK DWAYNE CHRISTENSEN SR. DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2006
-----------------------------------------------------
Last Update Date | 11/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6617 PRECINCT LINE RD, SUITE 100
-----------------------------------------------------
City | NORTH RICHLAND HILLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-595-2458
-----------------------------------------------------
Fax | 817-590-2468
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6617 PRECINCT LINE RD, SUITE 100
-----------------------------------------------------
City | NORTH RICHLAND HILLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-595-2458
-----------------------------------------------------
Fax | 817-590-2468
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 15137
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------