Provider Demographics
NPI:1386649333
Name:JENSEN, MICHAEL KENNETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENNETH
Last Name:JENSEN
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 1:3712 NE 131ST ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-4904
Mailing Address - Country:US
Mailing Address - Phone:360-574-8307
Mailing Address - Fax:360-253-9589
Practice Address - Street 1:406 SE 131ST AVE
Practice Address - Street 2:STE 202
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4004
Practice Address - Country:US
Practice Address - Phone:360-253-9542
Practice Address - Fax:360-253-9589
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD61671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice