Healthcare Provider Details

I. General information

NPI: 1891236055
Provider Name (Legal Business Name): GRACE HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5542 PALO VERDE ST
MONTCLAIR CA
91763-2538
US

IV. Provider business mailing address

5542 PALO VERDE ST
MONTCLAIR CA
91763-2538
US

V. Phone/Fax

Practice location:
  • Phone: 909-252-8170
  • Fax:
Mailing address:
  • Phone: 909-252-8170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA53687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: