Provider Demographics
NPI:1518232701
Name:JENSEN, NIELS
Entity Type:Individual
Prefix:DR
First Name:NIELS
Middle Name:
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 E MCLELLAN RD UNIT 3
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-3820
Mailing Address - Country:US
Mailing Address - Phone:702-335-3784
Mailing Address - Fax:
Practice Address - Street 1:6755 E SUPERSTITION SPRINGS BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4375
Practice Address - Country:US
Practice Address - Phone:702-335-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ91921223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics