Healthcare Provider Details

I. General information

NPI: 1306285671
Provider Name (Legal Business Name): NICHOLAS PAUL JENSEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 BROADMOOR BLVD NE
RIO RANCHO NM
87124-3442
US

IV. Provider business mailing address

770 BROADMOOR BLVD NE
RIO RANCHO NM
87124-3442
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-0554
  • Fax: 505-891-0552
Mailing address:
  • Phone: 505-891-0554
  • Fax: 505-891-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD3893
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: