Provider Demographics
NPI:1821247826
Name:JIMENEZ, LAURA YSOLINA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:YSOLINA
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17500 FOOTHILL BLVD STE C2
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3751
Mailing Address - Country:US
Mailing Address - Phone:909-357-7000
Mailing Address - Fax:
Practice Address - Street 1:17500 FOOTHILL BLVD STE C2
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3751
Practice Address - Country:US
Practice Address - Phone:909-357-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55254122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist