Provider Demographics
NPI:1366516791
Name:JENSEN, TONY MERRILL (DDS)
Entity type:Individual
Prefix:DR
First Name:TONY
Middle Name:MERRILL
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 1:1271 EAST MANFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020
Mailing Address - Country:US
Mailing Address - Phone:801-571-6663
Mailing Address - Fax:801-571-1219
Practice Address - Street 1:12226 S 1000 E
Practice Address - Street 2:SUITE #4
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8205
Practice Address - Country:US
Practice Address - Phone:801-571-6663
Practice Address - Fax:801-571-1219
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2665641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice