Healthcare Provider Details

I. General information

NPI: 1437716453
Provider Name (Legal Business Name): CARLOS HERNANDEZ D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CLEMENTE OROZCO #1506-203 ZONA URBANA RIO
TIJUANA BAJA CALIFORNIA
22010
MX

IV. Provider business mailing address

4492 CAMINO DE LA PLAZA #1441
SAN YSIDRO CA
92173-3129
US

V. Phone/Fax

Practice location:
  • Phone: 619-600-5265
  • Fax: 858-430-3143
Mailing address:
  • Phone: 619-600-5265
  • Fax: 858-430-3143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2894286
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: