Healthcare Provider Details

I. General information

NPI: 1932161825
Provider Name (Legal Business Name): STEPHEN RAY JENSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 MALL DR STE A
LAS CRUCES NM
88011-8193
US

IV. Provider business mailing address

2878 DIAMOND SPRINGS DR
LAS CRUCES NM
88011-5235
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-1779
  • Fax: 575-522-4789
Mailing address:
  • Phone: 808-840-7656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number52028788903
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD3479
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: