Provider Demographics
NPI:1891828778
Name:JIMENEZ, PETER NICHOLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:NICHOLAS
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31646 DUNLAP BLVD
Mailing Address - Street 2:STE.C
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-1602
Mailing Address - Country:US
Mailing Address - Phone:909-794-4909
Mailing Address - Fax:909-794-4904
Practice Address - Street 1:31646 DUNLAP BLVD
Practice Address - Street 2:SUITE #C
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-1602
Practice Address - Country:US
Practice Address - Phone:909-794-4909
Practice Address - Fax:909-794-4904
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA484711223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry