MEDICARE: DR. ROSITA C. JIMENEZ PERIODONTIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019.015877	IL
2	1223P0300X	Periodontics	021.001004	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DWP11770	OTHER	IL	DENTAL WELLNESS PARTNERS

General Provider Information

NPI Number	:	1356412530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROSITA C. JIMENEZ PERIODONTIST

Provider Business Mailing Address
First Line	:	3213 FOXRIDGE CT
Second Line	:
City	:	WOODRIDGE
State	:	IL
Zip	:	60517-3281
Country	:	US
Telephone Number	:	630-910-7213
Fax Number	:	773-762-0201

Provider Business Practice Location Address
First Line	:	2621 S LAWNDALE AVE
Second Line	:	SUITE B
City	:	CHICAGO
State	:	IL
Zip	:	60623-4520
Country	:	US
Telephone Number	:	773-762-0200
Fax Number	:	773-762-0201

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	03/01/2013

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