Provider Demographics
NPI:1699892042
Name:JENSEN, PHLLIP M (DMD)
Entity type:Individual
Prefix:DR
First Name:PHLLIP
Middle Name:M
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 1:2606 MARKETPLACE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-1467
Mailing Address - Country:US
Mailing Address - Phone:217-753-8690
Mailing Address - Fax:
Practice Address - Street 1:2606 MARKETPLACE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-1467
Practice Address - Country:US
Practice Address - Phone:217-753-8690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0208431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019020843Medicaid
IL033519OtherHEALTH ALLIANCE
IL442331OtherUNITED CONCORDIA
IL31898 33225OtherBCBS
IL033519OtherHEALTH ALLIANCE
ILU43366Medicare UPIN