Provider Demographics
NPI:1124410741
Name:JIMENEZ WOLF, ANDRES (DDS, MSD)
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:JIMENEZ WOLF
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E FORT AVE APT 803
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-5510
Mailing Address - Country:US
Mailing Address - Phone:305-979-8909
Mailing Address - Fax:
Practice Address - Street 1:193 US HIGHWAY 9 STE 2C
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3016
Practice Address - Country:US
Practice Address - Phone:732-409-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD167951223P0300X
PADS0415211223P0300X
DCDEN10022001223P0300X
NJ22DI028779001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics