Provider Demographics
NPI:1346222668
Name:JENSEN, PETER MARSHALL (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:MARSHALL
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 CAMINO DE SALUD NE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-4516
Mailing Address - Country:US
Mailing Address - Phone:505-925-4031
Mailing Address - Fax:505-925-7800
Practice Address - Street 1:1801 CAMINO DE SALUD NE
Practice Address - Street 2:SUITE 1200
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-4516
Practice Address - Country:US
Practice Address - Phone:505-925-4031
Practice Address - Fax:505-925-7800
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD19901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10075011Medicaid
NM10075011Medicaid