Healthcare Provider Details

I. General information

NPI: 1720576119
Provider Name (Legal Business Name): JAVIER HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12730 HAWTHORNE BLVD STE D
HAWTHORNE CA
90250-3919
US

IV. Provider business mailing address

1849 MARINE AVE
GARDENA CA
90249-3801
US

V. Phone/Fax

Practice location:
  • Phone: 310-644-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number43342
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: