Provider Demographics
NPI:1154874394
Name:JENSEN, BAILEY (RDH)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W MORELAND BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 W MORELAND BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2483
Practice Address - Country:US
Practice Address - Phone:414-651-3599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-24
Last Update Date:2016-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002944-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist