Healthcare Provider Details

I. General information

NPI: 1417098260
Provider Name (Legal Business Name): MARIO HERNADEZ, DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 FOREST HILL BLVD SUITE 103
LAKE CLARKE SHORES FL
33406-8901
US

IV. Provider business mailing address

1870 FOREST HILL BLVD SUITE 103
LAKE CLARKE SHORES FL
33406-8901
US

V. Phone/Fax

Practice location:
  • Phone: 561-585-5891
  • Fax: 561-586-6014
Mailing address:
  • Phone: 561-585-5891
  • Fax: 561-586-6014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number13087
License Number StateFL

VIII. Authorized Official

Name: MARIO HERNANDEZ
Title or Position: DENTIST
Credential: DDS
Phone: 561-585-5891