Provider Demographics
NPI:1588877591
Name:LJ PROFESSIONAL DENTAL PC
Entity type:Organization
Organization Name:LJ PROFESSIONAL DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:LIBIA
Authorized Official - Middle Name:REBECA
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-368-9532
Mailing Address - Street 1:600 W 146TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-4301
Mailing Address - Country:US
Mailing Address - Phone:212-368-9532
Mailing Address - Fax:212-368-2245
Practice Address - Street 1:600 W 146TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-4301
Practice Address - Country:US
Practice Address - Phone:212-368-9532
Practice Address - Fax:212-368-2245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0453071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty