Provider Demographics
NPI:1861912578
Name:JIMENEZ, MIRANDA ALISE (DDS)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ALISE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:ALISE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2121 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-2126
Mailing Address - Country:US
Mailing Address - Phone:816-983-5937
Mailing Address - Fax:
Practice Address - Street 1:2121 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2126
Practice Address - Country:US
Practice Address - Phone:816-429-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017021249122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist