Provider Demographics
NPI:1629835467
Name:JIMENEZ, LAURIE (RDH)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 ELM ST # 4719
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-9251
Mailing Address - Country:US
Mailing Address - Phone:703-944-0637
Mailing Address - Fax:
Practice Address - Street 1:900 CHAPEL ST APT RC245
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2822
Practice Address - Country:US
Practice Address - Phone:703-944-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402207265124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist