MEDICARE: DR. JERRY HERNANDEZ D.D.S.

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	0401413249	VA
2	1223G0001X	General Practice Dentistry	60539	CA

General Provider Information

NPI Number	:	1649565557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY HERNANDEZ D.D.S.

Provider Business Mailing Address
First Line	:	7484 UNIVERSITY AVE
Second Line	:	STE.#150
City	:	LA MESA
State	:	CA
Zip	:	91942-6063
Country	:	US
Telephone Number	:	619-460-2500
Fax Number	:	619-462-3169

Provider Business Practice Location Address
First Line	:	7484 UNIVERSITY AVE
Second Line	:	STE. 150
City	:	LA MESA
State	:	CA
Zip	:	91942-6063
Country	:	US
Telephone Number	:	619-460-2500
Fax Number	:	619-462-3169

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

Provider Enumeration Date	:	06/20/2011
Last Update Date	:	04/04/2012

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