Provider Demographics
NPI:1770210783
Name:MENJIVAR, KIMBERLY (RDH)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MENJIVAR
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-3531
Mailing Address - Country:US
Mailing Address - Phone:201-496-4246
Mailing Address - Fax:
Practice Address - Street 1:509 ORANGE ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-2128
Practice Address - Country:US
Practice Address - Phone:973-481-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22HI01177400124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist