Healthcare Provider Details

I. General information

NPI: 1104825363
Provider Name (Legal Business Name): MARK E. JENSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 SW SHEVLIN HIXON DR
BEND OR
97702-3201
US

IV. Provider business mailing address

199 SW SHEVLIN HIXON DR
BEND OR
97702-3201
US

V. Phone/Fax

Practice location:
  • Phone: 541-330-5952
  • Fax: 541-330-5935
Mailing address:
  • Phone: 541-330-5952
  • Fax: 541-330-5935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD6517
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: