MEDICARE: DR. PEDER J JENSEN D.M.D.

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	1223P0300X	Periodontics	2544	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2544	OTHER	AR	ARKANSAS DENTAL LICENSE

General Provider Information

NPI Number	:	1407907165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PEDER J JENSEN D.M.D.

Provider Business Mailing Address
First Line	:	2501 CRESTWOOD RD STE 102
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-7615
Country	:	US
Telephone Number	:	501-758-6182
Fax Number	:	501-758-6184

Provider Business Practice Location Address
First Line	:	2501 CRESTWOOD RD STE 102
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-7615
Country	:	US
Telephone Number	:	501-758-6182
Fax Number	:	501-758-6184

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

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	07/08/2007

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