Healthcare Provider Details

I. General information

NPI: 1750123675
Provider Name (Legal Business Name): KELLY J JENSEN LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 6TH AVE E STE 5
KALISPELL MT
59901-5005
US

IV. Provider business mailing address

725 6TH AVE E STE 5
KALISPELL MT
59901-5005
US

V. Phone/Fax

Practice location:
  • Phone: 406-314-4892
  • Fax: 406-314-4893
Mailing address:
  • Phone: 406-314-4892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDEN-DTR-LIC-7928
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: