Healthcare Provider Details

I. General information

NPI: 1659431526
Provider Name (Legal Business Name): ALAN CHARLES JENSEN DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1377 EAST 3900 SOUTH SUITE 203
SALT LAKE CITY UT
84124
US

IV. Provider business mailing address

1377 EAST 3900 SOUTH SUITE 203
SALT LAKE CITY UT
84124
US

V. Phone/Fax

Practice location:
  • Phone: 801-272-9900
  • Fax: 801-272-7704
Mailing address:
  • Phone: 801-272-9900
  • Fax: 801-272-7704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number144101-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: