MEDICARE: CHRISTENSEN FAMILY DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1720307259
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTENSEN FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	560 N STAPLEY DR
Second Line	:	STE 2
City	:	MESA
State	:	AZ
Zip	:	85203-7320
Country	:	US
Telephone Number	:	480-964-2131
Fax Number	:	480-964-7334

Provider Business Practice Location Address
First Line	:	560 N STAPLEY DR
Second Line	:	STE 2
City	:	MESA
State	:	AZ
Zip	:	85203-7320
Country	:	US
Telephone Number	:	480-964-2131
Fax Number	:	480-964-7334

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LEO B CHRISTENSEN
Credential	:	DDS
Telephone Number	:	317-670-9090

Provider Enumeration Date	:	05/24/2010
Last Update Date	:	05/24/2010

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