Provider Demographics
NPI:1023440146
Name:JENSEN, RUSSELL RAY (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:RAY
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 38TH ST SOUTH
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405
Mailing Address - Country:US
Mailing Address - Phone:801-592-5695
Mailing Address - Fax:
Practice Address - Street 1:1804 38TH ST SOUTH
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405
Practice Address - Country:US
Practice Address - Phone:801-592-5695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DEN-LIC-6013122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist