=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619168507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDWARD A. CHRISTENSEN, D.D.S, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 916 S MAIN ST UNIT 302
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-6672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-702-9501
-----------------------------------------------------
Fax | 303-532-2275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 916 S. MAIN STREET #302
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-702-9501
-----------------------------------------------------
Fax | 303-532-2275
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | KIMBER BARNEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-604-9500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------