MEDICARE: SAMUEL W. CHRISTENSEN

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	122300000X	Dentist	53776	CA

General Provider Information

NPI Number	:	1740730704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMUEL W. CHRISTENSEN

Provider Business Mailing Address
First Line	:	390 S GREEN VALLEY RD STE 5
Second Line	:
City	:	WATSONVILLE
State	:	CA
Zip	:	95076-3077
Country	:	US
Telephone Number	:	831-722-1432
Fax Number	:	831-722-7861

Provider Business Practice Location Address
First Line	:	390 S GREEN VALLEY RD STE 5
Second Line	:
City	:	WATSONVILLE
State	:	CA
Zip	:	95076-3077
Country	:	US
Telephone Number	:	831-722-1432
Fax Number	:	831-722-7861

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. SAMUEL WESLEY CHRISTENSEN
Credential	:	53776
Telephone Number	:	831-722-1432

Provider Enumeration Date	:	10/13/2016
Last Update Date	:	10/13/2016

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