Provider Demographics
NPI:1841304425
Name:JENSON, COLLEEN S (DMD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:S
Last Name:JENSON
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 1:825 CASPIAN CT E STE A
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-2844
Mailing Address - Country:US
Mailing Address - Phone:719-471-8318
Mailing Address - Fax:719-532-0488
Practice Address - Street 1:1155 KELLY JOHNSON BLVD STE 210
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3958
Practice Address - Country:US
Practice Address - Phone:719-532-1007
Practice Address - Fax:719-532-0488
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8739122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO432006564OtherEIN