Healthcare Provider Details

I. General information

NPI: 1689873523
Provider Name (Legal Business Name): FERNANDO JOSE JIMENEZ D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5139 LITTLE RD
NEW PORT RICHEY FL
34655-1212
US

IV. Provider business mailing address

143-3 CALLE 401 VILLA CAROLINA
CAROLINA PR
00985-4022
US

V. Phone/Fax

Practice location:
  • Phone: 813-336-8478
  • Fax:
Mailing address:
  • Phone: 787-200-5542
  • Fax: 787-200-5543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2769
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN 19685
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: