=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669662425
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KYLE S CHRISTENSEN, DDS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2007
-----------------------------------------------------
Last Update Date | 07/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1268 W SOUTH JORDAN PKWY SUITE 200
-----------------------------------------------------
City | SOUTH JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84095-4652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-561-8088
-----------------------------------------------------
Fax | 801-562-8286
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1268 W SOUTH JORDAN PKWY SUITE 200
-----------------------------------------------------
City | SOUTH JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84095-4652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-561-8088
-----------------------------------------------------
Fax | 801-562-8286
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KYLE S CHRISTENSEN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 801-561-8088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------