Provider Demographics
NPI:1538236823
Name:JENSEN, COREY CLARK
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:CLARK
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3475 PLYMOUTH BLVD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-1499
Mailing Address - Country:US
Mailing Address - Phone:763-537-1238
Mailing Address - Fax:763-537-4627
Practice Address - Street 1:3475 PLYMOUTH BLVD
Practice Address - Street 2:SUITE #100
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-1499
Practice Address - Country:US
Practice Address - Phone:763-537-1238
Practice Address - Fax:763-537-4627
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9970122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist