Provider Demographics
NPI:1316240112
Name:JENSEN, MICHAEL DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
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 1:6201 MARINA PACIFICA DR N
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-3875
Mailing Address - Country:US
Mailing Address - Phone:805-895-3257
Mailing Address - Fax:
Practice Address - Street 1:319 REDONDO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-2652
Practice Address - Country:US
Practice Address - Phone:562-433-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA594851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice