Provider Demographics
NPI:1881770089
Name:JENSEN, SCOTT MCKENZIE (DMD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:MCKENZIE
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 1:920 CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401
Mailing Address - Country:US
Mailing Address - Phone:336-379-1500
Mailing Address - Fax:336-379-8585
Practice Address - Street 1:920 CHERRY STREET
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401
Practice Address - Country:US
Practice Address - Phone:336-379-1500
Practice Address - Fax:336-379-8585
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC55551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8994548Medicaid
2414647AMedicare ID - Type Unspecified
NC8994548Medicaid