Provider Demographics
NPI:1225185440
Name:JENSON, DARREL JOE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DARREL
Middle Name:JOE
Last Name:JENSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 COBURG RD
Mailing Address - Street 2:BLDG 2
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4986
Mailing Address - Country:US
Mailing Address - Phone:541-342-3398
Mailing Address - Fax:541-342-1620
Practice Address - Street 1:1814 COBURG RD
Practice Address - Street 2:BLDG 2
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4986
Practice Address - Country:US
Practice Address - Phone:541-342-3398
Practice Address - Fax:541-342-1620
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD58261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR829878OtherUNITED CONCORDIA POVIDER
OR22853-6OtherOMAP POVIDER NUMBER