Provider Demographics
NPI:1427671825
Name:JENSEN, DYLAN JACOB (DMD)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:JACOB
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 1:488 W 150 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-1961
Mailing Address - Country:US
Mailing Address - Phone:801-319-1772
Mailing Address - Fax:
Practice Address - Street 1:3626 W 5600 S
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-9161
Practice Address - Country:US
Practice Address - Phone:801-985-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11775286-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty