Healthcare Provider Details

I. General information

NPI: 1629835467
Provider Name (Legal Business Name): LAURIE JIMENEZ RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2024
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CHAPEL ST APT RC245
NEW HAVEN CT
06510-2822
US

IV. Provider business mailing address

206 ELM ST # 4719
NEW HAVEN CT
06520-9251
US

V. Phone/Fax

Practice location:
  • Phone: 703-944-0637
  • Fax:
Mailing address:
  • Phone: 703-944-0637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402207265
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: