Provider Demographics
NPI:1699919126
Name:JIMENEZ, DAMIAN RICHARD
Entity type:Individual
Prefix:
First Name:DAMIAN
Middle Name:RICHARD
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 1:201 OGLETHORPE DR NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-2767
Mailing Address - Country:US
Mailing Address - Phone:404-323-3206
Mailing Address - Fax:
Practice Address - Street 1:5635 PEACHTREE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-2879
Practice Address - Country:US
Practice Address - Phone:404-990-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0149081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery