Provider Demographics
NPI:1598805822
Name:JENSEN, KURT FREDRIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:FREDRIC
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 1:6050 BRYNWOOD DR
Mailing Address - Street 2:STE 102
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6579
Mailing Address - Country:US
Mailing Address - Phone:815-877-0694
Mailing Address - Fax:815-877-4254
Practice Address - Street 1:6050 BRYNWOOD DR
Practice Address - Street 2:STE 102
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-6579
Practice Address - Country:US
Practice Address - Phone:815-877-0694
Practice Address - Fax:815-877-4254
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT39158Medicare UPIN