Provider Demographics
NPI:1043827488
Name:ULLOA-JIMENEZ, ERNESTO (DMD)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:ULLOA-JIMENEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 S WEST SHORE BLVD APT 3406
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-5654
Mailing Address - Country:US
Mailing Address - Phone:813-297-5497
Mailing Address - Fax:
Practice Address - Street 1:10845 BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3616
Practice Address - Country:US
Practice Address - Phone:813-662-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25501122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist