Healthcare Provider Details

I. General information

NPI: 1356412530
Provider Name (Legal Business Name): ROSITA C. JIMENEZ PERIODONTIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 S LAWNDALE AVE SUITE B
CHICAGO IL
60623-4520
US

IV. Provider business mailing address

3213 FOXRIDGE CT
WOODRIDGE IL
60517-3281
US

V. Phone/Fax

Practice location:
  • Phone: 773-762-0200
  • Fax: 773-762-0201
Mailing address:
  • Phone: 630-910-7213
  • Fax: 773-762-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.015877
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021.001004
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: