Provider Demographics
NPI:1750123675
Name:JENSEN, KELLY J (LD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 6TH AVE E STE 5
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-5005
Mailing Address - Country:US
Mailing Address - Phone:406-314-4892
Mailing Address - Fax:
Practice Address - Street 1:725 6TH AVE E STE 5
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-5005
Practice Address - Country:US
Practice Address - Phone:406-314-4892
Practice Address - Fax:406-314-4893
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DTR-LIC-7928122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist