Provider Demographics
NPI:1063673440
Name:PEDER JENSEN, DMD, PA
Entity Type:Organization
Organization Name:PEDER JENSEN, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ZELMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEYMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-758-6182
Mailing Address - Street 1:2501 CRESTWOOD RD
Mailing Address - Street 2:STE 102
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-6864
Mailing Address - Country:US
Mailing Address - Phone:501-758-6182
Mailing Address - Fax:501-758-6184
Practice Address - Street 1:2501 CRESTWOOD RD
Practice Address - Street 2:STE 102
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-6864
Practice Address - Country:US
Practice Address - Phone:501-758-6182
Practice Address - Fax:501-758-6184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR25441223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty