MEDICARE: DR. DILLON JENSEN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1134656275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DILLON JENSEN DDS

Provider Business Mailing Address
First Line	:	530 S WAKARA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1213
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2314 S 2200 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1529
Country	:	US
Telephone Number	:	801-824-2642
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2017
Last Update Date	:	02/07/2020

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