Healthcare Provider Details

I. General information

NPI: 1336274836
Provider Name (Legal Business Name): JUAN A JIMENEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 AVE DOMENECH
SAN JUAN PR
00918-3505
US

IV. Provider business mailing address

AVE DOMENECH 201
HATO REY PR
00918
US

V. Phone/Fax

Practice location:
  • Phone: 787-274-0634
  • Fax:
Mailing address:
  • Phone: 787-274-0634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number1463
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: