Healthcare Provider Details

I. General information

NPI: 1093647570
Provider Name (Legal Business Name): EDGAR IVAN HERNANDEZ CAMPOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E FLORIDA AVE
HEMET CA
92544-8640
US

IV. Provider business mailing address

4014 PAUL DR
HEMET CA
92545-9350
US

V. Phone/Fax

Practice location:
  • Phone: 951-765-5544
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: