Provider Demographics
NPI:1366617953
Name:JENSEN, BRIAN CLARK (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:CLARK
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5017
Mailing Address - Country:US
Mailing Address - Phone:208-939-3010
Mailing Address - Fax:
Practice Address - Street 1:1177 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5017
Practice Address - Country:US
Practice Address - Phone:208-939-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-38781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice