MEDICARE: JENS WILSON DMD

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	1223P0221X	Pediatric Dentistry	LL-541-20	NV
2	1223P0221X	Pediatric Dentistry	DD5597	NM

General Provider Information

NPI Number	:	1568089076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENS WILSON DMD

Provider Business Mailing Address
First Line	:	4760 N BUTLER AVE STE C
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-0816
Country	:	US
Telephone Number	:	435-459-4457
Fax Number	:

Provider Business Practice Location Address
First Line	:	2650 E PINON FRONTAGE RD BLDG 200
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87402-5084
Country	:	US
Telephone Number	:	505-599-9359
Fax Number	:

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

Provider Enumeration Date	:	06/30/2020
Last Update Date	:	10/02/2023

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Directions to “ JENS WILSON DMD” Practice Location

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