Healthcare Provider Details

I. General information

NPI: 1679638340
Provider Name (Legal Business Name): JON WILLIAM JENSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 E 800 N STE 203
OREM UT
84097-4437
US

IV. Provider business mailing address

1375 E 800 N STE 203
OREM UT
84097-4437
US

V. Phone/Fax

Practice location:
  • Phone: 801-404-5810
  • Fax: 801-404-5811
Mailing address:
  • Phone: 801-404-5810
  • Fax: 801-404-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6103356-9922
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: