Provider Demographics
NPI:1356412530
Name:JIMENEZ, ROSITA C (PERIODONTIST)
Entity type:Individual
Prefix:DR
First Name:ROSITA
Middle Name:C
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:PERIODONTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 FOXRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-3281
Mailing Address - Country:US
Mailing Address - Phone:630-910-7213
Mailing Address - Fax:773-762-0201
Practice Address - Street 1:2621 S LAWNDALE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4520
Practice Address - Country:US
Practice Address - Phone:773-762-0200
Practice Address - Fax:773-762-0201
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0158771223G0001X
IL021.0010041223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDWP11770OtherDENTAL WELLNESS PARTNERS