Healthcare Provider Details

I. General information

NPI: 1518232701
Provider Name (Legal Business Name): DR. NIELS JENSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6755 E SUPERSTITION SPRINGS BLVD STE 102
MESA AZ
85206-4375
US

IV. Provider business mailing address

3950 E MCLELLAN RD UNIT 3
MESA AZ
85205-3820
US

V. Phone/Fax

Practice location:
  • Phone: 702-335-3784
  • Fax:
Mailing address:
  • Phone: 702-335-3784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number9192
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: