Provider Demographics
NPI:1023410529
Name:JENSEN, HENRY CHARLES
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:CHARLES
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 S HIGGINS AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4226
Mailing Address - Country:US
Mailing Address - Phone:406-542-2742
Mailing Address - Fax:
Practice Address - Street 1:570 RIVERSTONE WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-2940
Practice Address - Country:US
Practice Address - Phone:907-455-4350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11581122300000X
AK1583122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist