Provider Demographics
NPI:1124096425
Name:JENSEN, DOUGLAS E (DDS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:E
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 1:823 LINCOLN LN
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-7401
Mailing Address - Country:US
Mailing Address - Phone:708-354-2024
Mailing Address - Fax:708-354-2070
Practice Address - Street 1:5540 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4418
Practice Address - Country:US
Practice Address - Phone:773-735-4434
Practice Address - Fax:773-735-4993
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190171351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10004342Medicaid