Healthcare Provider Details

I. General information

NPI: 1457893885
Provider Name (Legal Business Name): JOSE-JULIO HERNANDEZ-BLOUIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W WASHINGTON ST STE 1
SAN DIEGO CA
92103-1873
US

IV. Provider business mailing address

PO BOX 295
BONITA CA
91908-0295
US

V. Phone/Fax

Practice location:
  • Phone: 619-297-0700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS101007
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDDS101007
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: