Provider Demographics
NPI:1568622751
Name:JORGENSEN, DONALD L (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:L
Last Name:JORGENSEN
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 1:124 COLE SHOPPING CENTER
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001
Mailing Address - Country:US
Mailing Address - Phone:307-635-9202
Mailing Address - Fax:307-634-6112
Practice Address - Street 1:124 COLE SHOPPING CENTER
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001
Practice Address - Country:US
Practice Address - Phone:307-635-9202
Practice Address - Fax:307-634-6112
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO 1045481223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics