Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | PENDING | TX |
NPI | 1043862501 |
---|---|
Provider Name | Sarah Grace Jensen |
First Address | Fort Worth, TX 76109-2634 |
Second Address | Dallas, TX 75246-2013 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2019 |
Last Update Date | 15/07/2019 |