Provider Demographics
NPI:1245258748
Name:LIM, JENNIFER K (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:K
Last Name:LIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 MALACATE ST, BLDG B
Mailing Address - Street 2:
Mailing Address - City:AJO
Mailing Address - State:AZ
Mailing Address - Zip Code:85321
Mailing Address - Country:US
Mailing Address - Phone:520-387-4500
Mailing Address - Fax:520-387-3509
Practice Address - Street 1:410 N MALACATE ST BLDG B
Practice Address - Street 2:DESERT SENITA DENTAL CENTER
Practice Address - City:AJO
Practice Address - State:AZ
Practice Address - Zip Code:85321-2254
Practice Address - Country:US
Practice Address - Phone:520-387-4500
Practice Address - Fax:520-387-3509
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5942122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ910316OtherAHCCCS