Healthcare Provider Details

I. General information

NPI: 1639096209
Provider Name (Legal Business Name): FENDER MATIAS CRUZ JIMENEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 RANDALL BLVD
NAPLES FL
34120-5595
US

IV. Provider business mailing address

3210 RANDALL BLVD
NAPLES FL
34120-5595
US

V. Phone/Fax

Practice location:
  • Phone: 239-544-7596
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH28141
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: