Provider Demographics
NPI:1770005910
Name:BOUTON, JENSEN NICOLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENSEN
Middle Name:NICOLE
Last Name:BOUTON
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 1:4846 WILDE POINTE DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-3539
Mailing Address - Country:US
Mailing Address - Phone:407-617-8857
Mailing Address - Fax:
Practice Address - Street 1:8430 ENTERPRISE CIR STE 100
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-4111
Practice Address - Country:US
Practice Address - Phone:941-907-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22575122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist