Provider Demographics
NPI:1689740102
Name:ILIEN JIMENIZ MINTER DDS INC
Entity Type:Organization
Organization Name:ILIEN JIMENIZ MINTER DDS INC
Other - Org Name:GATEWAY DENTAL GATEWAY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ILIEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MINTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-485-8420
Mailing Address - Street 1:15725 POMERADO RD
Mailing Address - Street 2:STE 204
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064
Mailing Address - Country:US
Mailing Address - Phone:858-485-8420
Mailing Address - Fax:858-485-5773
Practice Address - Street 1:15725 POMERADO RD
Practice Address - Street 2:STE 204
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064
Practice Address - Country:US
Practice Address - Phone:858-485-8420
Practice Address - Fax:858-485-5773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA519741223G0001X
CADUO349331223G0001X
CA389121223G0001X
CA559191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTIN