Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 1001264-15 | WI |
NPI | 1003229618 |
---|---|
Provider Name | Dr. Nathan John Jensen |
First Address | New Richmond, WI 54017-2565 |
Second Address | New Richmond, WI 54017-2565 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2014 |
Last Update Date | 25/02/2016 |