Provider Demographics
NPI:1578636668
Name:JIMENEZ, LIBIA REBECA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LIBIA
Middle Name:REBECA
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:600 W 146TH ST
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-4301
Mailing Address - Country:US
Mailing Address - Phone:212-368-9532
Mailing Address - Fax:212-368-2245
Practice Address - Street 1:600 W 146TH ST
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-4301
Practice Address - Country:US
Practice Address - Phone:212-368-9532
Practice Address - Fax:212-368-2245
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045307-11223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01477283Medicaid