Provider Demographics
NPI:1386975258
Name:JENSEN, SCOTT LANE (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:LANE
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 1:15303 HUEBNER RD
Mailing Address - Street 2:BLDG. 17
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-0959
Mailing Address - Country:US
Mailing Address - Phone:210-696-2563
Mailing Address - Fax:
Practice Address - Street 1:15303 HUEBNER RD
Practice Address - Street 2:BLDG. 17
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78248-0959
Practice Address - Country:US
Practice Address - Phone:210-696-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-16
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31052122300000X, 1223P0221X
AZD75401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice