Healthcare Provider Details

I. General information

NPI: 1063673440
Provider Name (Legal Business Name): PEDER JENSEN, DMD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CRESTWOOD RD STE 102
NORTH LITTLE ROCK AR
72116-6864
US

IV. Provider business mailing address

2501 CRESTWOOD RD STE 102
NORTH LITTLE ROCK AR
72116-6864
US

V. Phone/Fax

Practice location:
  • Phone: 501-758-6182
  • Fax: 501-758-6184
Mailing address:
  • Phone: 501-758-6182
  • Fax: 501-758-6184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2544
License Number StateAR

VIII. Authorized Official

Name: ZELMA SEYMORE
Title or Position: OFFICE MANAGER
Credential:
Phone: 501-758-6182