Healthcare Provider Details

I. General information

NPI: 1154917334
Provider Name (Legal Business Name): GERMAN L FERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14815 N DALE MABRY HWY
TAMPA FL
33618-2027
US

IV. Provider business mailing address

19512 WYNDMILL CIR
ODESSA FL
33556-1717
US

V. Phone/Fax

Practice location:
  • Phone: 813-264-1993
  • Fax:
Mailing address:
  • Phone: 813-317-4686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number19080
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: