Provider Demographics
NPI:1083319776
Name:JIMENEZ, JOSEPH MIGUEL
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MIGUEL
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3046
Mailing Address - Country:US
Mailing Address - Phone:214-828-8215
Mailing Address - Fax:
Practice Address - Street 1:631 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3046
Practice Address - Country:US
Practice Address - Phone:864-308-1355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC108501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program