Provider Demographics
NPI:1578652327
Name:JENSEN, MARVIN FLETCHER (MD,DDS)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:FLETCHER
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MD,DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 W FOOTHILL BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3756
Mailing Address - Country:US
Mailing Address - Phone:909-931-9571
Mailing Address - Fax:909-931-9473
Practice Address - Street 1:930 W FOOTHILL BLVD STE C
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3756
Practice Address - Country:US
Practice Address - Phone:909-931-9571
Practice Address - Fax:909-931-9473
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA243081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery