Basic Information
| Provider Information | |||||||||
| NPI: | 1922059906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHRISTOPHE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | WENDELL | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 W REYNOSA AVE | ||||||||
| Address2: | |||||||||
| City: | DE LEON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764441630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548935895 | ||||||||
| FaxNumber: | 2548935222 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 RIVER NORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | STEPHENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764011804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2549652810 | ||||||||
| FaxNumber: | 2549655440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 4741-015 | WI | N | Dental Providers | Dentist | General Practice | 1223G0001X | 9307 | CO | N | Dental Providers | Dentist | General Practice | 1223G0001X | 20800 | TX | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1275830390 | 05 | TX | MEDICAID |