Provider Demographics
NPI:1487803433
Name:LAURA Y. JIMENEZ, DDS PROF. DENTAL CORP
Entity type:Organization
Organization Name:LAURA Y. JIMENEZ, DDS PROF. DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:YSOLINA
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-350-2598
Mailing Address - Street 1:17500 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3736
Mailing Address - Country:US
Mailing Address - Phone:909-357-7000
Mailing Address - Fax:
Practice Address - Street 1:17500 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3736
Practice Address - Country:US
Practice Address - Phone:909-357-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
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?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty