Provider Demographics
NPI:1134494289
Name:PHILLIP M. JENSEN, D.M.D., P.C.
Entity Type:Organization
Organization Name:PHILLIP M. JENSEN, D.M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-753-8690
Mailing Address - Street 1:2606 MARKETPLACE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-1467
Mailing Address - Country:US
Mailing Address - Phone:217-753-8690
Mailing Address - Fax:
Practice Address - Street 1:2606 MARKETPLACE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-1467
Practice Address - Country:US
Practice Address - Phone:217-753-8690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190208431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty