Provider Demographics
NPI:1902472723
Name:CHRISTIANSEN, WESLEY CARL (DDS)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:CARL
Last Name:CHRISTIANSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 LESLIE BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-3586
Mailing Address - Country:US
Mailing Address - Phone:573-635-6080
Mailing Address - Fax:
Practice Address - Street 1:913 LESLIE BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-3586
Practice Address - Country:US
Practice Address - Phone:573-635-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021019867122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist