Healthcare Provider Details

I. General information

NPI: 1487347738
Provider Name (Legal Business Name): MICHAEL HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 08/01/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL CAMP PENDLETON 200 MERCY CIRCLE
OCEANSIDE CA
92055
US

IV. Provider business mailing address

200 MERCY CIRCLE NAVAL HOSPITAL CAMP PENDLETON
OCEANSIDE CA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 760-719-3621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14096492-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: