MEDICARE: DR. RICHARD HOWARD JENSON D.D.S

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	122300000X	Dentist	5132387	UT

General Provider Information

NPI Number	:	1982620233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD HOWARD JENSON D.D.S

Provider Business Mailing Address
First Line	:	117 W FOREST ST
Second Line	:
City	:	BRIGHAM CITY
State	:	UT
Zip	:	84302-2013
Country	:	US
Telephone Number	:	435-723-8136
Fax Number	:	435-723-5988

Provider Business Practice Location Address
First Line	:	117 W FOREST ST
Second Line	:
City	:	BRIGHAM CITY
State	:	UT
Zip	:	84302-2013
Country	:	US
Telephone Number	:	435-723-8136
Fax Number	:	435-723-5988

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

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	07/08/2007

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