Provider Demographics
NPI:1093242711
Name:BORGENICHT-LOPEZ, JAIMIE CAROLINA (DMD)
Entity Type:Individual
Prefix:
First Name:JAIMIE
Middle Name:CAROLINA
Last Name:BORGENICHT-LOPEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JAIMIE
Other - Middle Name:CAROLINE
Other - Last Name:BORGENICHT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:131 NW 100TH AVE
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324
Mailing Address - Country:US
Mailing Address - Phone:321-945-6253
Mailing Address - Fax:954-476-7734
Practice Address - Street 1:131 NW 100TH AVE
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-7034
Practice Address - Country:US
Practice Address - Phone:954-476-4537
Practice Address - Fax:954-476-7734
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1672122300000X
FLDN24070122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1672OtherFLORIDA STATE BOARD OF DENTISTRY