Healthcare Provider Details

I. General information

NPI: 1881926509
Provider Name (Legal Business Name): DAYNE R JENSEN M.D., D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2010
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 NW 63RD ST
OKLAHOMA CITY OK
73116-5111
US

IV. Provider business mailing address

2100 NW 63RD ST
OKLAHOMA CITY OK
73116-5111
US

V. Phone/Fax

Practice location:
  • Phone: 405-842-6677
  • Fax:
Mailing address:
  • Phone: 405-842-6677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6860
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number30823
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: