=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285063297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHAD JENSEN DMD, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2013
-----------------------------------------------------
Last Update Date | 11/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 N MAIN ST
-----------------------------------------------------
City | HARRISON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72601-3536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-741-4746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 N MAIN ST
-----------------------------------------------------
City | HARRISON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72601-3536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-741-4746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHAD ERICK JENSEN
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 801-358-4479
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3968
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------