Provider Demographics
NPI:1598232308
Name:PETER N JIMENEZ DDS A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:PETER N JIMENEZ DDS A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:N
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-794-4909
Mailing Address - Street 1:31646 DUNLAP BLVD UNIT C
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-1689
Mailing Address - Country:US
Mailing Address - Phone:909-794-4909
Mailing Address - Fax:909-794-4904
Practice Address - Street 1:31646 DUNLAP BLVD UNIT C
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-1689
Practice Address - Country:US
Practice Address - Phone:909-794-4909
Practice Address - Fax:909-794-4904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty