=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861848673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M L CHRISTENSEN DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2016
-----------------------------------------------------
Last Update Date | 05/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 166 E 5900 S SUITE B101
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-7257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-262-1974
-----------------------------------------------------
Fax | 801-263-2064
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 166 E 5900 S SUITE B101
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-7257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-262-1974
-----------------------------------------------------
Fax | 801-263-2064
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK LYNNWOOD CHRISTENSEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 801-262-1974
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 139732-9922
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------