Basic Information
| Provider Information | |||||||||
| NPI: | 1346222668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | MARSHALL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 CAMINO DE SALUD NE | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871024516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059254031 | ||||||||
| FaxNumber: | 5059257800 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 CAMINO DE SALUD NE | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871024516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059254031 | ||||||||
| FaxNumber: | 5059257800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 05/04/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DD1990 | NM | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 10075011 | 05 | NM | MEDICAID |