Provider Demographics
NPI:1740406321
Name:JENSEN, LISA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7717 SW 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1725
Mailing Address - Country:US
Mailing Address - Phone:503-246-2564
Mailing Address - Fax:503-246-0748
Practice Address - Street 1:214 N RUSSELL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1620
Practice Address - Country:US
Practice Address - Phone:503-494-7428
Practice Address - Fax:503-284-1398
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8631122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist