Healthcare Provider Details

I. General information

NPI: 1497037402
Provider Name (Legal Business Name): STEPHEN RAY JENSEN DDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 09/15/2011
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

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDD3479
License Number StateNM

VIII. Authorized Official

Name: DR. STEPHEN JENSEN
Title or Position: ORTHODONTIST/OWNER
Credential: DDS
Phone: 575-522-1779