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General NPI Number Information
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NPI Number | 1124096425
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Entity Type | Individual
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Provider Name | DOUGLAS E. JENSEN DDS
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Gender | Male
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Dates
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Enumeration Date | 03/10/2006
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Last Update Date | 12/16/2014
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Provider Practice Location Address
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Address Line | 5540 S PULASKI RD
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City | CHICAGO
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State | IL
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Zip | 60629-4418
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Country | US
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Telephone | 773-735-4434
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Fax | 773-735-4993
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Provider Business Mailing Address
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Address Line | 823 LINCOLN LN
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City | LA GRANGE HIGHLANDS
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State | IL
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Zip | 60525-7401
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Country | US
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Telephone | 708-354-2024
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Fax | 708-354-2070
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019017135
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License Number State | IL
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