Provider Demographics
NPI:1689873523
Name:JIMENEZ, FERNANDO JOSE (DMD)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:JOSE
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143-3 CALLE 401
Mailing Address - Street 2:VILLA CAROLINA
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00985-4022
Mailing Address - Country:US
Mailing Address - Phone:787-200-5542
Mailing Address - Fax:787-200-5543
Practice Address - Street 1:1912 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4700
Practice Address - Country:US
Practice Address - Phone:813-567-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR27691223S0112X
FLDN 196851223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery