Provider Demographics
NPI:1932161825
Name:JENSEN, STEPHEN RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RAY
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2878 DIAMOND SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5235
Mailing Address - Country:US
Mailing Address - Phone:808-840-7656
Mailing Address - Fax:
Practice Address - Street 1:1161 MALL DR STE A
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8193
Practice Address - Country:US
Practice Address - Phone:575-522-1779
Practice Address - Fax:575-522-4789
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT520287889031223G0001X
NMDD34791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics