Healthcare Provider Details

I. General information

NPI: 1124510508
Provider Name (Legal Business Name): ROSA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 09/14/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4280 BEE RIDGE RD
SARASOTA FL
34233-2563
US

IV. Provider business mailing address

13801 TAMIAMI TRL STE B
NORTH PORT FL
34287-2017
US

V. Phone/Fax

Practice location:
  • Phone: 941-363-6381
  • Fax:
Mailing address:
  • Phone: 941-200-5812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN23380
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: