MEDICARE: DR. ELLIS I HERNANDEZ D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1352	PR

General Provider Information

NPI Number	:	1447257050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLIS I HERNANDEZ D.M.D.

Provider Business Mailing Address
First Line	:	PO BOX 193392
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00919-3392
Country	:	US
Telephone Number	:	787-781-3187
Fax Number	:	787-782-5547

Provider Business Practice Location Address
First Line	:	1212 CALLE CADIZ
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00920-3841
Country	:	US
Telephone Number	:	787-781-3187
Fax Number	:	787-782-5547

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2005
Last Update Date	:	07/18/2012

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