Basic Information
| Provider Information | |||||||||
| NPI: | 1437240405 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1090 NORTHCHASE PKWY SE STE 290 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300676402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789045665 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2650 BEACH BLVD STE 31 | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395314517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074237085 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 09/09/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 9234 | CO | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | 3720-13 | MS | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.